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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-3686

2. Registrant Information.

Registrant Reference Number: PROSAR case #: 1-33939668

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: CALIFORNIA

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: Gramoxone

  • Active Ingredient(s)
      • Unknown

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: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.


  • Gastrointestinal System
    • Symptom - Nausea
  • Respiratory System
    • Symptom - Decreased pulmonary function
    • Specify - worsening pulmonary function
  • Renal System
    • Symptom - Renal failure
  • General
    • Symptom - Death
  • Gastrointestinal System
    • Symptom - Sore throat

4. How long did the symptoms last?

Persisted until death

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.)

1-33939668 - The reporter, the lead nurse at the emergency room of (name), indicated that a patient was exposed to an herbicidal product containing the active ingredient Paraquat. The nurse reported that an adult female accidentally drank the product one day prior to initial contact with the registrant. The nurse believed the product had been placed in an inappropriate container and the patient ingested the product thinking that it was tea. The patient first presented to the emergency room at 11:57 am one day prior to initial contact and was administered activated charcoal and gastric lavage. At the time of initial contact, the reporter stated that the patients vital signs were stable and she looked fine although she had some remaining nausea. On follow-up call, one day later, the reporter indicted that the patient was doing well. On follow-up call, seven days later, the reporter indicated that the patient had some throat irritation, was monitored for a period of time but was then discharged from the hospital. The reporter was uncertain if the patient had actually been exposed to Paraquat. Twenty two days after initial contact the registrant received a call from the pesticide surveillance program in the department of pesticide regulation who stated that they had been notified that this patient was not discharged from the hospital but had suffered from worsening renal and respiratory function and seven days after initial contact was receiving dialysis. Fifteen days after initial contact the patient passed away. No further information is available.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.

Unknown formulation of paraquat had been inappropriately stored in an unmarked container.