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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-2817

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-30600188

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.

Country: CANADA

Prov / State: ALBERTA

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. Unknown

Product Name: Axial (nonspecific)

  • Active Ingredient(s)

PMRA Registration No. 28328      PMRA Submission No.       EPA Registration No.

Product Name: Quilt (nonspecific)

  • Active Ingredient(s)

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.

Medical Professional

2. Demographic information of data subject

Sex: Male

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

3. List all symptoms, using the selections below.


  • Respiratory System
    • Symptom - Respiratory distress

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?

7. Exposure scenario


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

Pesticide Spill

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.

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.)

1-30600188- The reporter, a health care professional, indicated a patient had been exposed to several herbicides. The reporter indicated the patient which was seen at her facility the day prior had been exposed to two registrant herbicides. The first contained the active ingredients azoxystrobin and propiconazole and the second pinoxaden. The product identification information given by the reporter was vague. She was unable to provide precise names and was unable to give registration numbers. She indicated, further, a third non-registrant product referred to as Libertymay also have been involved. The reporter stated she works in an emergency department (she did not clarify in what capacity) where the patient presented in the back of an ambulance. The adult male had spilled the products in the back of his truck earlier the same day, cleaned up while wearing cotton gloves, and then eaten food without first washing his hands. The reporter stated he had presented in respiratory distress and had been diagnosed with organophosphate poisoning. The reporter stated her primary motive for calling was occupational safety for the health care professionals who may work with the patient. The reporter described no additional exposure other than the primary patient. The reporter was advised none of the products described were organophosphates or known to be cholinesterase inhibitors. The caller was advised of proper precautions to take, and decontamination/treatment of the affected patient. The reporter was advised to investigate further as the diagnosis did not match the expectations of the products whose names were provided. On follow up three days later the reporter was unable to provide additional information other than to report that the patient had improved with a course of oral antibiotics. The symptoms described are not consistent with known effects of the registrants product(s). No further information is available.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.