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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-4669
2. Registrant Information.
Registrant Reference Number: PROSAR case #: 1-34403119
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.
24-JUL-135. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
Unknown
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.
Active(s)PMRA Registration No. 28072 PMRA Submission No. EPA Registration No.
Product Name: Touchdown Herbicide
- Active Ingredient(s)
- GLYPHOSATE (PRESENT AS POTASSIUM SALT)
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: Unknown
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: Female
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Gastrointestinal System
- Symptom - Sore throat
- Respiratory System
- Symptom - Coughing
- Gastrointestinal System
- Symptom - Other
- Specify - Discharge in the throat
- Symptom - Mouth Irritation
- Specify - sores in mouth, throat
4. How long did the symptoms last?
Unknown / Inconnu
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)
Application
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.
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.)
1-34403119 - The reporter indicated that she was exposed to an herbicide containing the active ingredient glyphosate. The reporter states that one month prior to initial contact with the registrant the farmer who owns the property where she lives sprayed his crops with this product. During product application the reporter was outside and indicates that she may have inhaled some of the product. Since that time the reporter has been suffering from a sore throat, cough, sores on the roof of her mouth and throat and discharge at the back of her throat. The reporter indicates that she went to the doctor one week prior to initial contact with the registrant and again one day prior to initial contact with the registrant. The reporter does not indicate if the doctor made a diagnosis or if any treatment was provided. The reporter was advised that inhalation of the product may cause transient respiratory irritation but the described symptoms are not consistent with the described exposure. The reporter was encouraged to continue working with her doctor to find an underlying cause and appropriate treatment for her symptoms. No further information is available.
To be determined by Registrant
14. Severity classification.
Moderate
