Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-0478

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-36054456

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.

25-JAN-14

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

6. Date incident was first observed.

25-JAN-14

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: Gramoxone (unspecified)

• Active Ingredient(s)
  • PARAQUAT
    • 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: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Nausea
  • Symptom - Vomiting
  • Symptom - Bloody vomit
  • Symptom - Diarrhea

• Renal System
  • Symptom - Renal failure
  • Symptom - Anuria

• Blood
  • Symptom - Hypoxemia
  • Specify - Hypoxic

• General
  • Symptom - Death

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?

2

Day(s) / Jour(s)

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.

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.)

1-36054456 - The reporter, a nurse in the ICU department of (name) Hospital, indicated that an adult male was exposed to an herbicide containing the active ingredient Paraquat. The reporter stated that earlier in the day an adult male had an argument with his wife and attempted suicide by drinking 8-10 ounces of a green liquid that the patient had brought home from his work in a cranberry juice bottle. Per the reporter the patients family had confirmed with the patients workplace that the name of the product was Gramoxone. The reporter had no additional product information. At the time of the initial call the ICU nurse indicated that the patient was nauseous, vomiting, had diarrhea and had just developed hematemesis. Blood work was normal at that time. On follow-up call, one day later, the patients ICU nurse indicated that the patient still had frequent bouts of vomiting and diarrhea. The vomit was no longer bloody but now the patient was not urinating. The patient was being treated with intravenous fluids, pain medications and nausea medications. His respiratory rate was normal on room air. On follow-up call, two days after the exposure, a staff member in the ICU indicated that the patient died during the night. Prior to death the ICU nurse indicated that the patients kidneys had stopped working and the patient was hypoxic. The family had elected a DNR status for the patient so treatment prior to death was limited to low doses of pain medications (Dilaudid and Ativan). No further information is available.

To be determined by Registrant

14. Severity classification.

Death

15. Provide supplemental information here.

The Paraquat Poisoning Guidelines were provided to the hospital.