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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-3197

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-23053066

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.

16-JUN-10

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

04-JUN-10

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. 29138      PMRA Submission No.       EPA Registration No.

Product Name: Broadband Herbicide

  • Active Ingredient(s)
    • FLORASULAM
    • PINOXADEN

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

  • Gastrointestinal System
    • Symptom - Diarrhea
    • Symptom - Stomach pain
    • Symptom - Stomach cramps

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?

No

6. b) For how long?

7. Exposure scenario

Unknown

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.

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>8 hrs <=24 hrs / > 8 h < = 24 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.)

1-23053066- The reporter calls to indicate exposure to an herbicide containing the active ingredients Pinoxaden, and Florasulam. The caller reports he first worked with the product 12 days prior to initial contact with the registrant. He did not specify whether this was an occupational exposure or how the product was used. He did not describe a discreet exposure or indicate through which avenue he was exposed. He reports he had worked with the product several times since that point most recently the day prior to the initial contact with the registrant. He reports he developed diarrhea and stomach cramps shortly after the first use. The symptoms persisted until he sought medical advice and treatment (unspecified date and treatment). The caller stated the physician treating him asked him to verify the active ingredient. The caller indicated he did not think his symptoms were product related. The caller was advised of the active ingredient and that the symptoms seen were not consistent with labeled use of the product.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

Symptoms are not consistent with exposure to the pesticide involved (pinoxaden or florsulam)