Health Canada
Symbol of the Government of Canada
Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-4608

2. Registrant Information.

Registrant Reference Number: PROSAR case #: 1-31412862

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.


Prov / State: GEORGIA

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: Gramaxone

  • Active Ingredient(s)
      • Unknown

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

Product Name: Glyphosate

  • 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: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.


  • Cardiovascular System
    • Symptom - Hypertension
  • Gastrointestinal System
    • Symptom - Sore throat
    • Symptom - Irritated throat
    • Specify - esophagitis
    • Symptom - Vomiting
  • Renal System
    • Symptom - Creatinine increased

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?


Day(s) / Jour(s)

7. Exposure scenario


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

Poisoning from ingestion of the pesticide

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.)

1-31412862 - The reporter, a physician, indicated that a patient was exposed to a registrant herbicidal product containing the active ingredient Paraquat and a non-registrant product with the active ingredient glyphosphate. The physician reported that 1.5 hours prior to initial contact with the registrant a (age) year old, male patient inadvertently ingested about 10mls of a mixture of non-registrant and registrant product which had been combined and put in a Lipton iced tea bottle by the patients friend. The caller indicated that as soon as the patient drank from the bottle he vomited and his emesis was colored blue. When first admitted to the emergency room the patient was suffering from hypertension which had resolved by the time of initial contact. The patient was admitted into the hospital and treated with acetylcysteine and intravenous fluids. Two days after initial contact with the registrant blood work showed an increase in creatinine to 2.2. Three days after initial contact with the registrant the patients nurse indicated that the patients creatinine was decreasing but that the patient was complaining of a sore throat. Endoscopy was performed five days after initial contact which revealed esophagitis. The patient was discharged from the hospital six days after initial contact and was treated on an outpatient basis for his esophagitis. No further information is available.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.