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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-1802
2. Registrant Information.
Registrant Reference Number: PROSAR Case #: 1-29460782
Registrant Name (Full Legal Name no abbreviations): Syngenta 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.
19-MAR-125. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
19-MAR-12Product 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. 28821 PMRA Submission No. EPA Registration No.
Product Name: Cruiser Maxx Beans
- Active Ingredient(s)
- 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: Other / Autre
Préciser le type: Soybean
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.
Other
2. Demographic information of data subject
Sex: Female
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- General
- Symptom - Fever
- Respiratory System
- Symptom - Shortness of breath
- Ear
- Symptom - Earache
- Respiratory System
- Symptom - Coughing
- Nervous and Muscular Systems
- Symptom - Headache
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
Occupational
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.
Respiratory
11. What was the length of exposure?
>2 hrs <=8 hrs / >2 h <=8 h
12. Time between exposure and onset of symptoms.
>2 hrs <=8 hrs / > 2 h < = 8 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.)
1-29460782- The reporter indicates a family member may have been exposed to an insecticidal fungicidal product containing the active ingredients thiamethoxam, fludioxonil, and metalaxyl-m. The reporter indicates his (age) old (weight) pound daughter was working with a local seed plant where the product was being applied to soybean seed. She had come home that day from work with shortness of breath, headache, earache, fever and a nonproductive cough. He reported she had been exposed while at work but did not describe a discreet incident, nor did he describe any personal protective equipment that may have been used. She was reported not to have asthma but to have seasonal allergies. The caller was advised to seek medical assistance. Inhalation exposure (assumed) may yield transitory respiratory irritation in healthy individuals but many of her symptoms may be more consistent with a respiratory tract infection of some sort. The caller was provided product literature for a physicians independent evaluation. The reporter did not respond to follow up attempts. No further information is available.
To be determined by Registrant
14. Severity classification.
Minor
