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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-4010
2. Registrant Information.
Registrant Reference Number: PROSAR Case # 1-23793247
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.
13-AUG-105. Location of incident.
Country: CANADA
Prov / State: SASKATCHEWAN
6. Date incident was first observed.
11-AUG-10Product 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. 26396 PMRA Submission No. EPA Registration No.
Product Name: Reglone Liquid Herbicide Desiccant
- Active Ingredient(s)
- DIQUAT
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 - Tingling skin
- Symptom - Irritated skin
- Symptom - Peeling skin
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Unknown
6. a) Was the person hospitalized?
Unknown
6. b) For how long?
7. Exposure scenario
Unknown
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)
Goggles
Chemical resistant gloves
10. Route(s) of exposure.
Skin
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.)
1-23793247- The reporter indicates he was exposed to an herbicide containing the active ingredient diquat dibromide. The caller indicates he was adding the concentrated product to a tank containing water (diluting the product) two days prior to the initial contact with the registrant. He reports he was wearing PPE that included goggles and gloves. As he added the product to the tank a splash from the surface of the water met his face. He indicates a ¿ inch area on the side of his face was affected. He immediately briefly rinsed the area. Later in the evening he noted a tingling sensation on the affected area. The next day he noted peeling skin on that area and superficial irritation. He reported his skin was intact at the time of exposure. The caller had not yet seen a doctor. The caller was informed prolonged exposure to concentrated solutions may result in severe skin irritation and burns. He was, further, informed that intact skin is typically an effective barrier to systemic absorption of the active ingredient following dermal exposure. The caller was advised of appropriate decontamination procedures and it was suggested he consult a physician for wound care assistance. The caller did not respond to follow up attempts. No further information is available.
To be determined by Registrant
14. Severity classification.
Minor
