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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2009-2551
2. Registrant Information.
Registrant Reference Number: Prosar 1-19107391
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.
08-JUL-095. Location of incident.
Country: CANADA
Prov / State: NEW BRUNSWICK
6. Date incident was first observed.
08-JUL-09Product 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. 28072 PMRA Submission No. EPA Registration No.
Product Name: Touchdown Total Herbicide
- Active Ingredient(s)
- GLYPHOSATE (PRESENT AS POTASSIUM 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: Unknown / Inconnu
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
The product was applied with a backpack sprayer on 07/08/2009.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: >12 <=19 yrs / >12 <=19 ans
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
- Symptom - Collapse
- Specify - "Fell over"
- Gastrointestinal System
- Symptom - Vomiting
- General
- Symptom - Dehydration
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Yes
6. a) Was the person hospitalized?
Yes
6. b) For how long?
Unknown
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Other
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.)
1-19107391: A reporter called to report the possible exposure of his son's friend to an herbicide containing the active ingredient Glyphosate. According to the reporter, the reporter's son was using a backpack sprayer to apply the product earlier that morning. The son's friend was near him while the product was being applied, but there was no known exposure. Several hours after the application, the friend went jogging. He fell down and vomited. At the time of the report, the friend was in the hospital. The reporter was advised that the diluted product has a wide range of safety. Furthermore, a substantial exposure would be required to result in any symptoms, and delayed development of signs would not be expected. A recommendation was made for the health care provider to rule out other potential causes for the signs. On follow up, the reporter stated that the friend was treated overnight for dehydration secondary to working in the sun all day and jogging. The friend was released the following morning and is fine. Product involvement was not suspected. No further information was obtained.
To be determined by Registrant
14. Severity classification.
Moderate
