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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-2797
2. Registrant Information.
Registrant Reference Number: PROSAR Case #: 1-30383713
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.
05-JUN-125. Location of incident.
Country: CANADA
Prov / State: QUEBEC
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. PMRA Submission No. EPA Registration No. Unknown
Product Name: Ratak (non-specific)
- Active Ingredient(s)
- BRODIFACOUM
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: Res. - In Home / Rés. - à l'int. maison
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: Female
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Respiratory System
- Symptom - Other
- Specify - sense of smell is affected
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
Non-occupational
8. How did exposure occur? (Select all that apply)
Application
Contact with treated area
What was the activity? primary residence (residing in)
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.
Unknown
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.)
1-30383713- The reporter indicated she had been exposed to a rodenticide containing the active ingredient brodifacoum. The reporter stated she had applied the product in her home in the cracks of the walls to control rodents. She did not describe application beyond that statement. She did not describe a time line. The reporter indicated she was forced to remove the product due to its aroma. She reported since the use she has had problems with her sense of smell-she is more sensitive to smells. The caller was advised to follow up wither physician the symptoms described are inconsistent with the described exposure and the toxicity profile of the active ingredient. The product has a slight cereal odor. It is unclear what aroma the caller may be referring to .The caller was not reached for follow up. No further information is available.
To be determined by Registrant
14. Severity classification.
Minor
