Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-6122

2. Registrant Information.

Registrant Reference Number: 1-35283745

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-OCT-13

5. Location of incident.

Country: UNITED STATES

Prov / State: FLORIDA

6. Date incident was first observed.

20-OCT-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. Unknown

Product Name: Diquat Dibromide

• Active Ingredient(s)
  • DIQUAT
    • Unknown

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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.

Medical Professional

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Vomiting

• Skin
  • Symptom - Edema
  • Symptom - Blister
  • Specify - blisters in mouth

• Gastrointestinal System
  • Symptom - Tongue swelling

• Skin
  • Symptom - Lesion
  • Specify - Sores in the mouth

• General
  • Symptom - Swelling
  • Specify - swelling of lips

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?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

Unknown

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.)

1-35283745 - The reporter, a physician, indicated that an adult male was exposed to an herbicide containing the active ingredient diquat dibromide and to a non-registrant product which contained ammonia. The reporter stated that on the day of initial contact an adult male ingested a combination of diquat and ammonia in an attempt to commit self-harm. Per the reporter the patient ingested a low concentration of diquat which they estimated to be in the range of 0.0XX%. Immediately after ingestion the patient vomited and at the time of the call the patient was being treated at the hospital. On follow-up call, one day later, a hospital employee indicated that the patient was still in the hospital and had some swelling of his lips and his tongue. On follow-up call, three days after the initial exposure, a hospital employee indicated that the patient was still in the hospital but was doing much better; he still had some blisters and sores in his mouth but it was expected that he would be discharged to the psych ward in the next day or two. No further information is available.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

Cannot confirm that this incident involved a Syngenta product as the caller reported a non-specific Diquat Dibromide product.