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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-5063

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-31410683

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


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. 100-896

Product Name: Avid 0.15 EC Miticide/Insecticide

  • 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).

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?


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.


  • Respiratory System
    • Symptom - Coughing
  • General
    • Symptom - Metallic taste in the mouth
    • Specify - Unpleasant taste
  • Skin
    • Symptom - Pruritus
  • Respiratory System
    • Symptom - Chest congestion
  • General
    • Symptom - Sweating
    • Specify - at night sweating a lot
  • Eye
    • Symptom - Miosis
    • Specify - small pupil
    • Symptom - Irritated eye
  • General
    • Symptom - Pain
    • Specify - Painful ribs
  • Skin
    • Symptom - Itchy skin
  • General
    • Symptom - Pain
    • Specify - bones in his chest hurt
  • Eye
    • Symptom - Burning eye

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)


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.)

1-31408661 - The reporter indicated that he was exposed to a miticidal product containing the active ingredient abamectin. The reporter, an adult male with previously diagnosed COPD, indicated that he applied this product in a room of his house one day prior to initial contact with the registrant. During application, the reporters sprayer was leaking and by the time the application was finished his clothes were soaked with the product. The room was open and fans were on while the product was applied and the reporter did wear a paper mask during application but he was not wearing any eye protection. The reporter did shower sometime after product application. Later that same day the reporter indicated that he developed a bad metallic taste in his mouth, his skin was itchy, he was coughing up a lot of material and that night he was sweating a lot. On the day of initial contact with the registrant the reporter indicated that he was coughing, he felt like the bones in his chest hurt, he still had a bad taste in his mouth, and it felt like his eyes were burning and his pupils were small. The reporter was advised product inhalation, ocular exposure, and dermal contact may elicit transitory irritation. He was instructed in proper decontamination and the threshold at which he might seek medical assistance should symptoms persist or worsen. No further information is available.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.