Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-5114

2. Registrant Information.

Registrant Reference Number: 1-34675631

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.

20-AUG-13

5. Location of incident.

Country: UNITED STATES

Prov / State: NEW JERSEY

6. Date incident was first observed.

19-AUG-13

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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 100-1431

Product Name: Gramoxone 2.0 SL

• Active Ingredient(s)
  • PARAQUAT
    • Guarantee/concentration 30.1 %

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7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

No

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?

Unknown

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

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

• General
  • Symptom - Lethargy

• Blood
  • Symptom - Acidosis
  • Symptom - Other
  • Specify - Hyperkalemia

• Renal System
  • Symptom - Creatinine increased
  • Symptom - Anuria

• Cardiovascular System
  • Symptom - Tachycardia

• General
  • Symptom - Hypothermia

• Cardiovascular System
  • Symptom - Hypotension

• Blood
  • Symptom - Hyperglycemia

• General
  • Symptom - Fever
  • Symptom - Death

• Renal System
  • Symptom - Dialysis required

• Respiratory System
  • Symptom - Decreased pulmonary function

4. How long did the symptoms last?

Persisted until death

5. Was medical treatment provided? Provide details in question 13.

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

6

Day(s) / Jour(s)

7. Exposure scenario

Occupational

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)

Unknown

10. Route(s) of exposure.

Oral

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.)

1-34675631 - The reporter, a worker at the (state) Poison Control, indicated that an adult male was exposed to an herbicidal product containing the active ingredient Paraquat. The reporter stated that a (age) year old, adult male was at work at a landscape company when he told his co-workers that he wanted to commit suicide. He went into a storeroom and was gone for 10 minutes and when he came out he was drinking some iced tea that had the product added to it. Right after drinking the mixture the patient vomited and within an hour of ingestion the patient was lethargic. He was brought to the hospital where he was sedated, gastric lavage was performed, and activated charcoal or fullers earth were given. After decontamination the patient was intubated and placed on supplemental oxygen. On the day of exposure the patients BUN was 14 and his creatinine was 1.0, he was hyperkalemic and acidotic (7.24) and later in the day he became anuric. On the day of initial contact he was tachycardic, hypothermic and still anuric. His BUN had increased to 37 and creatinine had increased to 4.4. The potassium had decreased to 4.8. On follow-up call to the hospital, two days after the exposure, a nurse at the hospital stated that the patient was hypotensive (108/73) and on vasopressors, he was acidotic, pyremic (104F), hyperglycemic (but this was thought to be a lab error) and his creatinine was 4.9. He had received dialysis on the day he was admitted into the hospital and the following day. On follow-up call, three days after the exposure, a doctor indicated that the patients oxygen saturation had worsened and as a consequence his inspired oxygen had been increased from 35% to 50%. At 50% inspired oxygen the patients saturation was 94%. The patients heart rate was 170-180 beats per minute and his blood pressure was down to 84/47 in spite of being treated with two different vasopressors. Per the doctor they were unable to perform dialysis over the last two days because of the patients hemodynamic issues. The BUN had increased to 44, the creatinine was 7.6, and the patient was still anuric. On follow-up call, four days after the exposure, the patients blood pressure was down to 71/35 and his heart rate was 152 beats per minute. The BUN was 56, the creatinine was 8.4 and he was still anuric. On follow up call, nine days after the exposure, the doctor indicated that the patient had passed away six days after the exposure. No further information is available.

To be determined by Registrant

14. Severity classification.

Death

15. Provide supplemental information here.