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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-4914
2. Registrant Information.
Registrant Reference Number: 1-34864064
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.
06-SEP-135. Location of incident.
Country: CANADA
Prov / State: QUEBEC
6. Date incident was first observed.
12-AUG-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. 26980 PMRA Submission No. EPA Registration No.
Product Name: Vanquish Herbicide
- Active Ingredient(s)
- DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, OR SODIUM 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: Res. - Out Home / Rés - à l'ext.maison
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
- Skin
- Symptom - Itchy skin
- Respiratory System
- Symptom - Respiratory irritation
- Gastrointestinal System
- Symptom - Irritated throat
- Nervous and Muscular Systems
- Symptom - Headache
4. How long did the symptoms last?
>24 hrs <=3 days / >24 h <=3 jours
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
Non-occupational
8. How did exposure occur? (Select all that apply)
Contact with treated area
What was the activity? Walked through the application site
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.
Skin
Respiratory
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
<=30 min / <=30 min
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.)
1-34864064 - The reporter indicated that both she (Subform III #1) and a child (Subform III #2) were exposed to an herbicide containing the active ingredient Dicamba. The reporter stated that the product was applied in her neighbors yard sixteen days prior to initial contact with the registrant and at the time of application the reporters windows were open and per the reporter the fumes were strong and she developed a sore throat. The reporter then walked to her neighbors house, brushed against some foliage where product had been applied and it made her skin itch. The reporter came back home, showered and the itching resolved but she had respiratory irritation, a headache and sore throat that persisted for 2 days. The reporter also indicated that a child (Subform III #2) who was in her home at the time developed a headache that persisted for 2 days. No medical treatment was needed for either patient. No further information is available.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
Subform II: Human Incident Report (A separate form for each person affected)
1. Source of Report.
Other
2. Demographic information of data subject
Sex: Unknown
Age: >1 <=6 yrs / > 1 < = 6 ans
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
- Symptom - Headache
4. How long did the symptoms last?
>24 hrs <=3 days / >24 h <=3 jours
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
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.
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.)
1-34864064 - The reporter indicated that both she (Subform III #1) and a child (Subform III #2) were exposed to an herbicide containing the active ingredient Dicamba. The reporter stated that the product was applied in her neighbors yard sixteen days prior to initial contact with the registrant and at the time of application the reporters windows were open and per the reporter the fumes were strong and she developed a sore throat. The reporter then walked to her neighbors house, brushed against some foliage where product had been applied and it made her skin itch. The reporter came back home, showered and the itching resolved but she had respiratory irritation, a headache and sore throat that persisted for 2 days. The reporter also indicated that a child (Subform III #2) who was in her home at the time developed a headache that persisted for 2 days. No medical treatment was needed for either patient. No further information is available.
To be determined by Registrant
14. Severity classification.
Minor
