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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-4451

2. Registrant Information.

Registrant Reference Number: PROSAR case #: 1-34360284

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: UNKNOWN

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. 100-834

Product Name: Barricade 65 WG

  • Active Ingredient(s)

PMRA Registration No.       PMRA Submission No.       EPA Registration No. 100-1091

Product Name: Reward Landscape and Aquatic Herbicide

  • Active Ingredient(s)
    • DIQUAT
      • Guarantee/concentration 37.3 %

PMRA Registration No.       PMRA Submission No.       EPA Registration No. 100-1084

Product Name: Fusilade II turf and ornamental herbicide

  • Active Ingredient(s)
      • Guarantee/concentration 24.5 %

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

Product Name: Daconil 2787 Flowable Fungicide

  • Active Ingredient(s)
      • Guarantee/concentration 40.4 %

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.


2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • General
    • Symptom - Other
    • Specify - Myeolodysplastic syndrome
    • Symptom - Other
    • Specify - "toxic injury to internal organs"

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?

>1 yr / > 1 an

12. Time between exposure and onset of symptoms.

>6 mos / > 6 mois

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.)

1-34360284 - The reporter, a registrant employee, indicated that an adult male was exposed to numerous registrant herbicides and fungicides containing the active ingredients prodiamine, diquat, Fluazifop-p-butyl and Chlorothalonil and to numerous non-registrant products with unknown active ingredients. The reporter indicated that the registrants legal department was made aware of the case on September 11, 2012 and litigation for the case is currently pending. Per the reporter an adult male alleges that he was exposed to numerous chemicals through his work (occupation was not provided) in the time period spanning from 1989 to 2011. Sometime around February 20ll the patient was hospitalized and diagnosed with myeolodysplastic syndrome. The patient also alleges that he suffered from other unnamed toxic injuries to unspecified internal organs. The amount of time the patient stayed in the hospital, the treatment provided and the duration of symptoms was not provided. No further information is available.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.