Print | Need Larger Text?

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2587

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-26461837

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: CANADA

Prov / State: SASKATCHEWAN

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. 26638      PMRA Submission No.       EPA Registration No.

Product Name: Helix Xtra Seed Treatment

• Active Ingredient(s)
  • DIFENOCONAZOLE
  • FLUDIOXONIL
  • METALAXYL-M (MEFENOXAM)
  • THIAMETHOXAM

7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Unknown / Inconnu

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

• Gastrointestinal System
  • Symptom - Diarrhea

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.

Yes

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

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

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.)

1-26461837- The reporter calls to indicated exposure to a pesticide containing the active ingredients Thiamethoxam, Difenoconazole, Metalaxyl-M, and Fludioxonil. The reporter, an adult male, indicates he was working with the product three weeks ago placing the product in a seed spreader. He did not further clarify the environment in which the work was done. He indicted possible dermal and inhalation exposure but could not describe a discreet exposure incident. The reporter indicated three weeks ago he also developed diarrhea. He stated he has been evaluated by a physician and had tests for E. Coli among other thing. He asks if possible exposure may be related to chronic diarrhea. The reporter was advised of the potential short lived gastrointestinal irritant effect that may follow direct ingestion exposure. He was, further, advised the time line and symptoms described were inconsistent with the proposed avenue of exposure and the toxicity profile of the active ingredients. He was advised to continue to work with his health care provider to determine both the etiology and appropriate care for his symptoms.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.