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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-3048

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-26738405

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.



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. Unknown

Product Name: Gramoxone (non-specific)

  • Active Ingredient(s)
      • Unknown

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.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • Skin
    • Symptom - Erythema
    • Symptom - Blister
    • Symptom - Burns (2nd or 3rd degree)

4. How long did the symptoms last?

>1 wk <=1 mo / > 1 sem < = 1 mois

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.)

1-26738405- The reporter indicated exposure to an herbicide containing the active ingredient paraquat. It was reported an adult male was pouring the product into a sprayer at which point the product was spilled under his arm. The exposure had taken place five day prior to the registrant initially becoming aware of the incident. The exposed individual did not rinse the exposed area until the evening he was exposed. It was conveyed he was exposed at 10:30 am that day. The following day the exposed individual noted a 'red sunburn-like circle' under his arm three inches in diameter. The next day the symptoms worsened. The area expanded to five to six inches in diameter and became reddish purple in color. Later the same day the area became blistered. The next day the area became larger (four by eight inches) and the patient went to see a doctor. The doctor referred the patient to a local burn center. He was seen at the burn center four days following the exposure where he was diagnosed with second degree burns and treated. The patient was reported to have had cadaver skin applied to the area. No response was available initially to registrant follow up attempts. Spontaneous call back was received four weeks following the initial incident. It was discovered from the retailer that had sold the patient the product that the cadaver skin graft had not taken and the patient had to go back to the original burn center and have and auto skin graft taken from his thigh and applied to his underarm area. No further information is available regarding this case.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.

Label directions were not followed in terms of first aid procedures. The label states that spills are to be rinsed off immediately, it was several hours until the patient was able to rinse the spill from his skin.