Health Canada
Symbol of the Government of Canada
Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-2219

2. Registrant Information.

Registrant Reference Number: PROSAR Case : 1-30141312

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.


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. 100-1091

Product Name: Reward Landscape And Aquatic Herbicide

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

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: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.


  • Gastrointestinal System
    • Symptom - Vomiting
    • Symptom - Irritated throat
  • Renal System
    • Symptom - Other
    • Specify - enzyme elevation
  • Skin
    • Symptom - Burns (2nd or 3rd degree)
    • Specify - burns to esophagus
  • Renal System
    • Symptom - Creatinine increased
  • Gastrointestinal System
    • Symptom - Mouth Irritation
    • Specify - oral ulceration

4. How long did the symptoms last?

Unknown / Inconnu

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


6. a) Was the person hospitalized?


6. b) For how long?


Day(s) / Jour(s)

7. Exposure scenario


8. How did exposure occur? (Select all that apply)

Poisoning from ingestion of the pesticide

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.

<=30 min / <=30 min

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.)

1-30141312- the reporter called to indicate exposure to an herbicide containing the active ingredient Diquat. The reporter indicated just preceding his call he had placed the concentrated product in a beverage bottle for transport to the field for use. He had inadvertently taken a drink from that beverage bottle. He estimated consumption of one fluid ounce. The caller was advised of appropriate first aid on the scene and directed to seek immediate medical attention, emergency medical transport if necessary. The reporter spontaneously called back thirty minutes later. He reported he spontaneously vomited and felt much better. He asked if he still needed to see the doctor. The caller was once again directed to seek immediate medical attention, emergency medical transport if necessary. Within twenty minutes an emergency room physician attending the patient called. He described a hemodynamically stable patient with oral irritation. His plan was supportive care (intravenous fluids, Zofran, and a chemistry profile). The physician was advised of standards of care following the described exposure. He revised his plan to include chest radiograph, liver profile, and EKG. He reported he would also consider keeping the patient in the hospital for observation. Product literature was supplied to the physician via FAX. On follow up one day later the registrant was unable to contact a health care provider involved in the patients care. The patient was admitted to the hospital but was in the midst of transfer between departments. On follow up one additional day later the registrant was able to contact the nurse caring for the patient. She indicated the patient was well. He was walking the floors and asking to go home. He was reported to have an ulceration in his mouth and had a slightly elevated creatinine the day prior which was repeated but the result was pending. Following several unsuccessful follow attempts the patient was reached himself four days later. He reported he had been released from the hospital the day prior after his upper gastrointestinal tract was scoped. He indicated he had burns to his esophagus but his stomach and small intestine were unaffected. He was given medication for this which he could not list. He reported he felt much better and his kidney enzyme elevation had fully resolved. He indicated his doctor had stated he should make a full recovery, but had set a recheck appointment in five weeks to assure he had healed well. The patient was unwilling to provide his doctors name for further follow up when asked. No further information is available.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.