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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2014-4244
2. Registrant Information.
Registrant Reference Number: PROSAR case number: 1-38176989 and 1-38167158
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.
Domestic Animal
4. Date registrant was first informed of the incident.
19-AUG-145. Location of incident.
Country: UNITED STATES
Prov / State: IOWA
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. PMRA Submission No. EPA Registration No. 100-1325
Product Name: Flexstar GT Herbicide
- Active Ingredient(s)
- FOMESAFEN
- Guarantee/concentration 6.72 %
- GLYPHOSATE
- Guarantee/concentration 25.6 %
- FOMESAFEN
7. b) Type of formulation.
Liquid
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 III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Bird - Poultry / Oiseau - Volaille
3. Breed
Unknown
4. Number of animals affected
3
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Oral
Respiratory
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
<=30 min / <=30 min
11. List all symptoms
System
- General
- Symptom - Death
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
No
14. a) Was the animal hospitalized?
No
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
16. How was the animal exposed?
Spray drift / Dérive de pulvérisation
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1-38176989 and 1-38167158 - The reporter, a farmer, indicated that 60 chickens were exposed to a registrant herbicide containing the active ingredients fomesafen and glyphosate acid and to two non-registrant herbicides with the active ingredients glyphosate and clethodim. The reporter states that 5-2 weeks prior to initial contact with the registrant the herbicide was applied on an adjacent property about 100 feet from her fence line. At the time of application there was a 22-28 mph southerly wind. Thirty minutes after application the reporter went outside and found 3 dead chickens (Subform III #1) in a movable cage, which was near the fence line. Three days later one more chicken was found dead (Subform III #2). The reporter indicated that all the dead chickens were young and no chickens from the flock had died prior to the exposure and none have died since the fourth died. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Bird - Poultry / Oiseau - Volaille
3. Breed
Unknown
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Oral
Respiratory
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>24 hrs <=3 days / >24 h <=3 jours
11. List all symptoms
System
- General
- Symptom - Death
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
No
14. a) Was the animal hospitalized?
No
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
16. How was the animal exposed?
Spray drift / Dérive de pulvérisation
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1-38176989 and 1-38167158 - The reporter, a farmer, indicated that 60 chickens were exposed to a registrant herbicide containing the active ingredients fomesafen and glyphosate acid and to two non-registrant herbicides with the active ingredients glyphosate and clethodim. The reporter states that 5-2 weeks prior to initial contact with the registrant the herbicide was applied on an adjacent property about 100 feet from her fence line. At the time of application there was a 22-28 mph southerly wind. Thirty minutes after application the reporter went outside and found 3 dead chickens (Subform III #1) in a movable cage, which was near the fence line. Three days later one more chicken was found dead (Subform III #2). The reporter indicated that all the dead chickens were young and no chickens from the flock had died prior to the exposure and none have died since the fourth died. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
