Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2018-0425
2. Registrant Information.
Registrant Reference Number: ProPharma Group case #: 1-51030152
Registrant Name (Full Legal Name no abbreviations): Syngenta Canada Inc.
Address: 140 Research Lane, Research Park
City: Guelph
Prov / State: Ontario
Country: Canada
Postal Code: N1G4Z3
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
12-JAN-18
5. Location of incident.
Country: CANADA
Prov / State: QUEBEC
6. Date incident was first observed.
Unknown
Product Description
7. a) Provide the active ingredient and, if available, the registration number and product name (include all tank mixes). If the product is not registered provide a submission number.
Active(s)
PMRA Registration No. 26980
PMRA Submission No.
EPA Registration No. Unknown
Product Name: VANQUISH HERBICIDE
- Active Ingredient(s)
- DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, OR SODIUM SALT)
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Agricultural-Outdoor/Agricole-extérieur
Préciser le type: Unknown
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
1-51030152 - The reporter indicated he would spray 4000-5000 liters of the product a day.
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Unknown
Subform II: Human Incident Report (A separate form for each person affected)
1. Source of Report.
Data Subject
2. Demographic information of data subject
Sex: Male
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
- Respiratory System
- Symptom - Other
- Specify - "pulmonary problems"
- Symptom - Coughing
- Nervous and Muscular Systems
- Symptom - Muscle weakness
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Unknown
6. a) Was the person hospitalized?
Unknown
6. b) For how long?
7. Exposure scenario
Occupational
8. How did exposure occur? (Select all that apply)
Application
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
Unknown
10. Route(s) of exposure.
Unknown
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
Unknown / Inconnu
13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)
1-51030152 - The reporter indicates an exposure to a pesticide containing the active ingredient dicamba (present as acid, amine salt, ester, or sodium salt). Approximately two years before the day of initial contact with the registrant, the reporter indicates he had been employed to spray the product for an unknown amount of days. The reporter did not remember if the product has been diluted or not. At the time of initial exposure, the reporter indicated he felt nauseated, dizzy, developed muscle weakness, and had a cough for an unknown amount of time after exposure. The reporter indicated the initial symptoms went away after an unknown amount of time, but he now has pulmonary problems and wants to know if they could be related to the exposure. The reporter was advised that symptoms from exposure to the product would be expected to last no more than an hour and he should continue to work with his doctor to find the cause of his current symptoms. No additional information is available..
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.