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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-5814

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-23915741

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.

25-AUG-10

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

6. Date incident was first observed.

25-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 - Red 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)

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.

Skin

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 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.)

1-23915741- The reporter indicates he was exposed to an herbicide containing the active ingredient diquat dibromide. The caller stated he was working with a tank of product four to five hours before the initial contact with registrant. He reports the hose on the sprayer broke and the product sprayed him in the face, neck, and back of neck. The reporter indicates he rinsed immediately but it was several hours after the initial exposure when he was able to go home and shower and fully decontaminate. The caller reports two hours after the exposure he had dermal redness on his face and neck. The caller describes healthy intact skin and no pre-existing lesions. The caller was unclear as to whether he was working with dilute or concentrated product when he was exposed. The caller was advised of the irritant effect of the product on intact skin. He was advised of the proper decontamination procedures, over the counter symptomatic management and the threshold at which he should seek medical advice. The reporter did not respond to follow up attempts.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.