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: 2010-5210

2. Registrant Information.

Registrant Reference Number: PROSAR Case#: 1-23388689

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: MANITOBA

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. 15723      PMRA Submission No.       EPA Registration No.

Product Name: Bravo 500

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


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?


Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.


2. Demographic information of data subject

Sex: Male

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.


  • Eye
    • Symptom - Swollen eye
    • Symptom - Red eye

4. How long did the symptoms last?

>24 hrs <=3 days / >24 h <=3 jours

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)


10. Route(s) of exposure.


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.)

1-23388689- The reporter calls to indicate exposure of a family member to a fungicide containing the active ingredient Chlorothalonil. The caller states her father was ¿¿¿spraying¿¿¿ the product the day prior to the initial contact with the registrant. She did not indicate in what capacity he was spraying the product or application technique/rate. Further, she did not indicate if any personal protective equipment used, nor did she describe a discreet exposure incident. She indicated the morning after product use her father demonstrated symptoms of ocular redness and ocular swelling. He was reported to be currently visiting the doctor and she was requesting a MSDS to provide the health care professional. A MSDS was provided which indicated the product could be a severe eye irritant, and prolonged or frequently repeated skin contact may cause allergic reaction in some individuals. On routine call back the reporter indicated her father¿¿¿s physician prescribed antihistamines and topical ocular corticosteroids. He was, at the time of the call back symptom free. No further information is available.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.