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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-2796
2. Registrant Information.
Registrant Reference Number: PROSAR Case #: 1-30360761
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.
04-JUN-125. Location of incident.
Country: CANADA
Prov / State: ONTARIO
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.
Active(s)PMRA Registration No. 29201 PMRA Submission No. EPA Registration No.
Product Name: Traxion
- Active Ingredient(s)
- GLYPHOSATE (PRESENT AS POTASSIUM SALT)
PMRA Registration No. 28072 PMRA Submission No. EPA Registration No.
Product Name: Touchdown Total Herbicide
- Active Ingredient(s)
- GLYPHOSATE (PRESENT AS POTASSIUM SALT)
7. b) Type of formulation.
Application Information
8. Product was applied?
No
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: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Paresthesia
- General
- Symptom - Sweating
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
No
6. a) Was the person hospitalized?
No
6. b) For how long?
7. Exposure scenario
Occupational
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.
Skin
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
>1 wk <=1 mo / > 1 sem < = 1 mois
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.)
1-30360761- The reporter indicated he was exposed to two herbicides both containing the active ingredient glyphosate. The reporter sated he had lent a pump to his neighbor. The neighbor used the pump but it had broken prior to returning it. The neighbor had indicated he had used the product Traxion associated with the equipment, but the reporter indicated he had seen evidence of the product Touchdown Total while rebuilding the pump. The reporter rebuilt the pump working on the equipment with bare hands. He reports in the one and one half weeks since he had the dermal exposure he has experienced prickly sensations on his hands and they are sweaty. The caller was advised the symptoms and time line are inconsistent with the expectation of either product. Transient dermal irritation may be experienced following dermal exposure which would typically resolve after he had washed his hands. He was advised to follow up with his physician. No follow up was obtained from the reporter. No further information is available.
To be determined by Registrant
14. Severity classification.
Minor
