Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-2141

2. Registrant Information.

Registrant Reference Number: ProPharma Group case #: 1-52372058

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-MAY-18

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

6. Date incident was first observed.

12-MAY-18

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)

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PMRA Registration No. 25585      PMRA Submission No.       EPA Registration No. Unknown

Product Name: APRON XL LS FUNGICIDE

• Active Ingredient(s)
  • METALAXYL-M (MEFENOXAM)

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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: chickpea

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

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.

Other

2. Demographic information of data subject

Sex: Male

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Fever

• Gastrointestinal System
  • Symptom - Gagging

• Eye
  • Symptom - Swollen eye

• Nervous and Muscular Systems
  • Symptom - Shaking

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.

Oral

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.)

1-52372058 - The reporter indicates an exposure to an herbicide containing the active ingredient metalaxyl-M (mefenoxam). One day before the day of initial contact with the registrant, the reporter indicated her father was applying the product all day and later that evening was shaking, febrile, and gagging. On the day of initial contact, those symptoms had subsided but his eyes were swelling. The reporter was told the symptoms would be unusual from normal product use, but to seek medical attention due to the severity of the symptoms. No additional information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.