Health Canada
Symbol of the Government of Canada
Consumer Product Safety

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-10

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

6. Date incident was first observed.

11-AUG-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. 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

15. Provide supplemental information here.