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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-3381
2. Registrant Information.
Registrant Reference Number: PROSAR Case#:1-33862900
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.
01-JUN-135. Location of incident.
Country: CANADA
Prov / State: ALBERTA
6. Date incident was first observed.
01-JUN-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. PMRA Submission No. EPA Registration No. Unknown
Product Name: Cruiser Maxx
- Active Ingredient(s)
- DIFENOCONAZOLE
- METALAXYL-M (MEFENOXAM)
- THIAMETHOXAM
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Agricultural-Outdoor/Agricole-extérieur
Préciser le type: Wheat
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
- Gastrointestinal System
- Symptom - Vomiting
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)
Contact with treated area
What was the activity? Ingested wheat from the field after the product had been applied
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.
Oral
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.)
1-33862900 - The reporter indicated that he was exposed to a fungicide and pesticide mixture with the active ingredients thiamethoxam, metalaxyl-m and difenoconazole. The reporter stated that just prior to initial contact with the registrant he had been in the field and he chewed on a piece of wheat that had recently been treated with this product. At the time of the initial call the reporter indicated that he felt nauseous. The reporter was advised that the product has a wide margin of safety and ingestion may result in transient gastrointestinal irritation. The reporter could not be reached on follow-up. No further information is available, including if it was a treated seed that he chewed on, or if there were any foliar treatments that were on the wheat; a seed treatment application is applied before the seed goes into the ground, so unlikely that it would be on the wheat blade.
To be determined by Registrant
14. Severity classification.
Minor
