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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-6499

2. Registrant Information.

Registrant Reference Number: PROSAR Case 1-15177548

Registrant Name (Full Legal Name no abbreviations): Syngenta Crop Protection

Address: 410 Swing Road

City: Greensboro

Prov / State: North Carolina

Country: USA

Postal Code: 27419

3. Select the appropriate subform(s) for the incident.


4. Date registrant was first informed of the incident.


5. Location of incident.


Prov / State: ARKANSAS

6. Date incident was first observed.


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.


PMRA Registration No.       PMRA Submission No.       EPA Registration No.

Product Name: Gramoxone Max - EPA: 100-1074

  • Active Ingredient(s)
      • Guarantee/concentration 43.8 %

7. b) Type of formulation.


Application Information

8. Product was applied?


9. Application Rate.


10. Site pesticide was applied to (select all that apply).

Site: Other / Autre

Préciser le type: Workplace

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?


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.


  • Skin
    • Symptom - Discolouration
    • Symptom - Dry skin
    • Symptom - Other
    • Specify - Flaky Skin and Nails

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


8. How did exposure occur? (Select all that apply)


9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)


10. Route(s) of exposure.


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.)

History: Per caller, used at workplace to manage yard. Used frequently at work, from about 5 yrs ago, up until ~1 yr ago. Caller states he frequently spilled AI on to left hand, as he was measuring out the concentrated product. Skin turned green after spilling onto him. Greenness persisted despite washing. Denies the use of any other products or chemicals at workplace. For about the past 1 year, skin on left hands looks dry and flaky. Dry / flakiness most prominent around joints. Fingernails on left hand appear flakey -- look like they are getting chewed down to the nub. Saw MD regarding SX. GP/MD thought symptoms were fungal symptoms. No treatments given per caller. Assessment: Caller asking my legal opinion of his situation, if there were legal ramifications. Told caller this is health service -- no legal expertise. No legal discussions would be done, period. As symptoms not resolving, to dermatologist for evaluation/treatment. Rule out fungal, dietary causes of SX. As symptoms persisting 1 yr, no home first aid thought to be useful. To MD for evaluation.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.