Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2007-5938
2. Registrant Information.
Registrant Reference Number: PROSAR Case 1-15163011
Registrant Name (Full Legal Name no abbreviations): Syngenta Crop Protection 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.
30-JUL-07
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
30-JUL-07
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. 24984
PMRA Submission No.
EPA Registration No.
Product Name: Matador 120EC Emulsifiable Concentrate Insecticide
7. b) Type of formulation.
Application Information
8. Product was applied?
Unknown
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
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.
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
- Skin
- Symptom - Irritated skin
- Symptom - Erythema
4. How long did the symptoms last?
>24 hrs <=3 days / >24 h <=3 jours
5. Was medical treatment provided? Provide details in question 13.
No
6. a) Was the person hospitalized?
Unknown
6. b) For how long?
7. Exposure scenario
Non-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.
Skin
11. What was the length of exposure?
<=15 min / <=15 min
12. Time between exposure and onset of symptoms.
>2 hrs <=8 hrs / > 2 h < = 8 h
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.)
History Caller spilled the product around 10 AM and it splashed up around his nose and eyes. He doesn't think he got any in his eyes. He washed with soap and water but about 3 hours later his face started burning and it's turning a little red. He is wondering what to do? Assessment - Skin exposure may cause a burning, itching, tingling, or numbness sensation. - Symptoms typically develop soon after the exposure and resolve spontaneously within 24 hours. - Recommend washing again with water and a mild detergent soap - You may apply a light coating of Vitamin E oil every four hours as needed. Vitamin E oil may help reduce the intensity and duration of the sensation. - Consult a health care professional if symptoms persist for more than 24 hours. - Please call back with any additional questions or concerns. 08/03/2007 Follow-up Patient states that he is doing fine now. He had symptoms for 1.5 days. He applied Vitamin E oil which helped.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.