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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-2800
2. Registrant Information.
Registrant Reference Number: PROSAR Case #: 1-30474741
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.
12-JUN-125. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
23-MAY-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 Seed Treatment
- Active Ingredient(s)
- FLUDIOXONIL
- METALAXYL-M (MEFENOXAM)
- THIAMETHOXAM
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: >6 <=12 yrs / > 6 < = 12 ans
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Blister
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.
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)
Contact with treated area
What was the activity? Child handling treated beans
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.
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.)
1-30474741- The reporter, an employee of the registrant, indicated a child was exposed to seed (beans) treated with the fungicides/insecticide metalaxyl-m, Fludioxonil, and thiamethoxam. The caller reported the incident to the medical service for the registrant. Subsequently the parent of the affected child was contacted. The mother of the (age) (numbe) pound male child reported her son had picked up three treated beans twenty days prior to the initial report. She indicates the child had experienced blistering on the surface of his hands shortly after handling the beans. She did not clarify the duration between exposure and onset or describe any decontamination following exposure. The child was not seen by a doctor but fully resolved within one and one half weeks with symptomatic care that was not described by the parent. The parent also added the child had been camping just before the development of the symptoms. She implied he had engaged in activities which may have led to the observed symptoms. Blistering would not be expected following dermal exposure to beans treated with these active ingredients. No further information is available.
To be determined by Registrant
14. Severity classification.
Moderate
