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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-5212

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-24123324

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.


Prov / State: GEORGIA

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.       PMRA Submission No.       EPA Registration No. 100-1217

Product Name: Gramoxone Inteon

  • Active Ingredient(s)
      • Guarantee/concentration 30.1 %

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: >12 <=19 yrs / >12 <=19 ans

3. List all symptoms, using the selections below.


  • Skin
    • Symptom - Burns (2nd or 3rd degree)
    • Specify - dermal "chemical burns" unspecified degree
    • Symptom - Irritated skin

4. How long did the symptoms last?

Unknown / Inconnu

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)

Pesticide Spill

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.

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

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.)

1-24123324- The reporter indicates a co-worker was exposed to an herbicide containing the active ingredient Paraquat. The reporter indicated a co-worker had been exposed to the diluted product (1:1 with water) via a spill on his abdomen. The exposure took place one week prior to the initial contact with the registrant. The spill was reported to be localized to the skin ¿¿¿mostly on his stomach?. The exposed party was reported to have left work shortly following the exposure. It is unclear what decontamination was done following the exposure. The exposed party was reported to have the product on is clothing, it is unknown if this clothing was promptly removed. The individual exposed did not go to the doctor immediately following the exposure. Two days after the exposure the party complained of skin burns described to be ¿¿¿like a sun burn?. He was reported to have gone to the emergency room and have been briefly hospitalized (duration not clarified). The hospitalization was reported to have been in a burn center where the patient received a skin transplantation or skin grafts for the treatment of ¿¿¿scrotal chemical burns?. No further information is available about the reported exposure. Chemical burns requiring skin grafts would be unexpected to occur following dermal exposure to diluted product.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.

Symptoms are not consistent with exposure to Paraquat. No evidence of direct exposure.