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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-4284

2. Registrant Information.

Registrant Reference Number: Prosar 1-19720635

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.


4. Date registrant was first informed of the incident.


5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

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. 8661      PMRA Submission No.       EPA Registration No.

Product Name: Gramoxone

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


Other Units: part/100 parts water

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

Site: Res. - Out Home / Rés - à l'

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

The product was applied at a dilution of 1 part product per 100 parts water on 08/31/2009.

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: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • Gastrointestinal System
    • Symptom - Irritated throat
    • Symptom - Diarrhea

4. How long did the symptoms last?

>2 hrs <=8 hrs / > 2 h < = 8 h

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)

Coveralls (non-chemical resistant)

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.)

1-19720635: A reporter called on 09/01/2009 to report his exposure to an herbicide containing the active ingredient Paraquat. According to the reporter, the product was diluted to 1 part product per 100 parts water. He applied it on 08/31/2009 and was wearing a rainproof yellow suit. During application, the wind shifted and the reporter was able to smell the product and thinks he inhaled some. After using the product, the caller removed the rainproof suit and the clothes underneath, and took a 15 minute shower. He noted minor throat irritation at some point that had resolved at the time of the report. The reporter stated that he developed diarrhea the afternoon of the report. The reporter was advised that systemic toxicity is unlikely with the described exposure. Aerosolized droplets from properly mixed preparations are not able to reach the area of the pulmonary system where they would result in toxicity. Inhaled product mist may result in irritation to the nose and upper respiratory tract. The reporter was advised that diarrhea is not expected to result from the described exposure. A recommendation was made to ensure adequate hydration and to consult a health care provider should the signs persist or worsen. On follow up, the reporter stated that his diarrhea resolved within hours and was likely unrelated to the product exposure. He did not need to see a physician. No further information was obtained.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.