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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-2822
2. Registrant Information.
Registrant Reference Number: PROSAR Case # 1 30685904
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
Packaging Failure
4. Date registrant was first informed of the incident.
29-JUN-125. Location of incident.
Country: CANADA
Prov / State: ALBERTA
6. Date incident was first observed.
28-JUN-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. 28328 PMRA Submission No. EPA Registration No.
Product Name: Quilt
- Active Ingredient(s)
- AZOXYSTROBIN
- PROPICONAZOLE
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
- Respiratory System
- Symptom - Nasal congestion
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
Unknown
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)
None
10. Route(s) of exposure.
Skin
11. What was the length of exposure?
>15 min <=2 hrs / >15 min <=2 h
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 30685904 The reporter indicated he had been exposed to a fungicidal product containing the active ingredients azoxystrobin and propiconazole. The reporter indicated he picked up a jug of the product from his local distributor the day prior to his initial report. He placed the jug into his vehicle and noted moisture on his hand. He indicated that the substance on his hand was the product and promptly washed his hand. He indicated he briefly experienced nasal congestion at the same time frame which had spontaneously resolved. He explained he frequently responds this way when exposed to various chemicals and attributed the symptom to an individual sensitivity. The reporter indicated he determined the product had been spilled due to the closure or cap being cross threaded. He indicated he used the remainder of the product and experienced no further heath issues. Nasal congestion would not be expected following dermal exposure to this product. No further information is available.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
Subform VI: Packaging Failure
1. What is the type of packaging that failed?
Jug-plastic / Cruche-plastique
2. Did packaging failure occur during?
Transportation
3. Did packaging failure result in?
potential injury
potential exposure
4. Describe how the packaging failed and the surrounding circumstances, including a description of the potential injury or exposure.
1-30685904- The reporter indicated he had been exposed to a fungicidal product containing the active ingredients azoxystrobin and propiconazole. The reporter indicated he picked up a jug of the product from his local distributor the day prior to his initial report. He placed the jug into his vehicle and noted moisture on his hand. He indicated that the substance on his hand was the product and promptly washed his hand. He indicated he briefly experienced nasal congestion at the same time frame which had spontaneously resolved. He explained he frequently responds this way when exposed to various chemicals and attributed the symptom to an individual sensitivity. The reporter indicated he determined the product had been spilled due to the closure or cap being 真真真cross threaded真真真. He indicated he used the remainder of the product and experienced no further heath issues. Nasal congestion would not be expected following dermal exposure to this product. No further information is available.
