Print | Need Larger Text?

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-0844

2. Registrant Information.

Registrant Reference Number: Prosar 1-16693601

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.

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

6. Date incident was first observed.

Unknown

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. 100-1091

Product Name: Reward Landscape And Aquatic Herbicide

• Active Ingredient(s)
  • DIQUAT
    • Guarantee/concentration 37.3 %

7. b) Type of formulation.

Liquid

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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Nausea
  • Symptom - Diarrhea
  • Symptom - Stomach pain
  • Specify - "Abdominal pain"

• Respiratory System
  • Symptom - Asthma
  • Symptom - Other
  • Specify - "Lost some sense of smell"
  • Symptom - Other
  • Specify - "Respiratory problems"

• Nervous and Muscular Systems
  • Symptom - Headache
  • Symptom - Dizziness
  • Symptom - Memory loss
  • Symptom - Other
  • Specify - "Nervous system disorders"

• General
  • Symptom - Other
  • Specify - "Sleep disturbances"

• Nervous and Muscular Systems
  • Symptom - Muscle pain

• General
  • Symptom - Joint pain

• Eye
  • Symptom - Blurred vision

• General
  • Symptom - Sleepiness
  • Specify - "Chronic fatigue syndrome"

• Nervous and Muscular Systems
  • Symptom - Other
  • Specify - "Fibromyalgia"

• General
  • Symptom - Lethargy

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)

Unknown

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

>1 yr / > 1 an

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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.)

1-16693601: A written report was received on 09/23/2008 detailing the exposure of a male to a contact herbicide containing the active ingredient Diquat Dibromide. According to the reporter, he had worked with this product and several other pesticides for 6 years. At some unspecified time after product exposure, the reporter developed multiple symptoms including: ¿¿¿respiratory problems?, asthma, headaches, dizziness, blurred vision, abdominal pain, muscle and joint pain, nausea, diarrhea, impaired memory, ¿¿¿nervous system disorders?, sleep disturbances, lethargy and a partial loss of his sense of smell. He also reported the development of chronic fatigue syndrome and fibromyalgia. The reporter stated that he is unable to perform any physical labor as he becomes fatigued easily. He also remains very sensitive to the odors of certain chemicals and develops headaches and dizziness when in contact with them. The reporter requested compensation for his presumed reaction to the product. Note: This case was received via mail and no further information was obtained. The details regarding exposure, product use, and what other products were used concurrently are not available in this report.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

This case was received via mail and no further information was obtained. The details regarding exposure (including manner of exposure), product use, and what other products were used concurrently are not available in this report.