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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-2266
2. Registrant Information.
Registrant Reference Number: PROSAR Case#:1-32569268
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.
27-JAN-135. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
27-JAN-13Product 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. 18450 PMRA Submission No. EPA Registration No.
Product Name: AAtrex Liquid 480 Agricultural Herbicide
- Active Ingredient(s)
- ATRAZINE (PLUS RELATED ACTIVE TRIAZINES)
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.
Other
2. Demographic information of data subject
Sex: Male
Age: >12 <=19 yrs / >12 <=19 ans
3. List all symptoms, using the selections below.
System
- Cardiovascular System
- Symptom - Chest pain
4. How long did the symptoms last?
>30 min <=2 hrs / >30 min <=2 h
5. Was medical treatment provided? Provide details in question 13.
Yes
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)
Other
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.
Respiratory
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
>30 min <=2 hrs / >30 min <=2 h
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.)
1-32569268 - The reporter indicated that his son was exposed to an herbicide containing the active ingredient atrazine. The reporter indicated that on the day of initial contact he made a fire in a barrel that contained some registrant product residue. The reporters (age) year old son was near the fire for about 1.5 hours and about 1.5 hours later complained of chest pain. The chest pain then resolved for a period of time but then returned about 30 minutes prior to initial contact with the registrant and was still a concern at the time of the call. The reporter was advised that the product is not meant to be heated; atrazine may let off corrosive gases if heated to hot enough temperatures. Evaluation by a health care professional was recommended. On follow-up call one day later the reporter indicated that his sons chest pain resolved shortly after speaking with the registrant. His son was evaluated at the emergency room but they did not find any health problems and no treatment was given. No further information is available.
To be determined by Registrant
14. Severity classification.
Minor
