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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2014-4950
2. Registrant Information.
Registrant Reference Number: PROSAR case number: 1-38588326
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.
29-SEP-145. Location of incident.
Country: CANADA
Prov / State: QUEBEC
6. Date incident was first observed.
26-SEP-14Product 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. 27428 PMRA Submission No. EPA Registration No.
Product Name: Demand CS
- Active Ingredient(s)
- LAMBDA-CYHALOTHRIN
PMRA Registration No. 30075 PMRA Submission No. EPA Registration No.
Product Name: Bedlam Insecticide
- Active Ingredient(s)
- D-PHENOTHRIN
- N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
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. - In Home / Rés. - à l'int. 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: Male
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Itchy skin
- Symptom - Paresthesia
- Gastrointestinal System
- Symptom - Irritated throat
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Unknown
6. a) Was the person hospitalized?
Unknown
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? Normal daily activities
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.)
1-38588326 - The reporter, a home owner, indicated that his family was exposed to a registrant insecticide containing the active ingredient Lambda-cyhalothrin and to a non-registrant product called Bedlam containing unknown active ingredients. The reporter stated that the product was applied in his secondary home by a pest control operator to treat bedbugs five days prior to initial contact with the registrant. It took the PCO 6 hours to apply the product. The callers family was not in the home during application. The caller quickly re-entered the home 1 hour after application was complete to open the windows and then he left. His family re-entered the home 2 days after product application and stayed the night. The family developed symptoms that night. The product was completely dry at the time of re-entry but the dry residue was evident and touched. The reporter states that everybody in his family including himself (Subform II #1) and his wife (Subform II #2) as well as his (age) year old (Subform II #4), (age) year old (Subform II #5) and (age) year old (Subform II #3) children developed throat irritation and itchy and burning skin; especially under the eyes. The callers (age) year old daughter also developed red skin under her eyes and her chest felt heavy. The following day the family was outside most of the day and the symptoms resolved but when they went back inside that evening the symptoms returned. 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: Female
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Itchy skin
- Symptom - Paresthesia
- Gastrointestinal System
- Symptom - Irritated throat
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Unknown
6. a) Was the person hospitalized?
Unknown
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? Normal daily activities
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.)
1-38588326 - The reporter, a home owner, indicated that his family was exposed to a registrant insecticide containing the active ingredient Lambda-cyhalothrin and to a non-registrant product called Bedlam containing unknown active ingredients. The reporter stated that the product was applied in his secondary home by a pest control operator to treat bedbugs five days prior to initial contact with the registrant. It took the PCO 6 hours to apply the product. The callers family was not in the home during application. The caller quickly re-entered the home 1 hour after application was complete to open the windows and then he left. His family re-entered the home 2 days after product application and stayed the night. The family developed symptoms that night. The product was completely dry at the time of re-entry but the dry residue was evident and touched. The reporter states that everybody in his family including himself (Subform II #1) and his wife (Subform II #2) as well as his (age) year old (Subform II #4), (age) year old (Subform II #5) and (age) year old (Subform II #3) children developed throat irritation and itchy and burning skin; especially under the eyes. The callers (age) year old daughter also developed red skin under her eyes and her chest felt heavy. The following day the family was outside most of the day and the symptoms resolved but when they went back inside that evening the symptoms returned. 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: Female
Age: >12 <=19 yrs / >12 <=19 ans
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Itchy skin
- Symptom - Paresthesia
- Respiratory System
- Symptom - Respiratory irritation
- Skin
- Symptom - Erythema
- Gastrointestinal System
- Symptom - Irritated throat
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Unknown
6. a) Was the person hospitalized?
Unknown
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? Normal daily activities
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.)
1-38588326 - The reporter, a home owner, indicated that his family was exposed to a registrant insecticide containing the active ingredient Lambda-cyhalothrin and to a non-registrant product called Bedlam containing unknown active ingredients. The reporter stated that the product was applied in his secondary home by a pest control operator to treat bedbugs five days prior to initial contact with the registrant. It took the PCO 6 hours to apply the product. The callers family was not in the home during application. The caller quickly re-entered the home 1 hour after application was complete to open the windows and then he left. His family re-entered the home 2 days after product application and stayed the night. The family developed symptoms that night. The product was completely dry at the time of re-entry but the dry residue was evident and touched. The reporter states that everybody in his family including himself (Subform II #1) and his wife (Subform II #2) as well as his (age) year old (Subform II #4), (age) year old (Subform II #5) and (age) year old (Subform II #3) children developed throat irritation and itchy and burning skin; especially under the eyes. The callers (age) year old daughter also developed red skin under her eyes and her chest felt heavy. The following day the family was outside most of the day and the symptoms resolved but when they went back inside that evening the symptoms returned. 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: >6 <=12 yrs / > 6 < = 12 ans
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Paresthesia
- Symptom - Itchy skin
- Gastrointestinal System
- Symptom - Irritated throat
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Unknown
6. a) Was the person hospitalized?
Unknown
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? Normal daily activities
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.)
1-38588326 - The reporter, a home owner, indicated that his family was exposed to a registrant insecticide containing the active ingredient Lambda-cyhalothrin and to a non-registrant product called Bedlam containing unknown active ingredients. The reporter stated that the product was applied in his secondary home by a pest control operator to treat bedbugs five days prior to initial contact with the registrant. It took the PCO 6 hours to apply the product. The callers family was not in the home during application. The caller quickly re-entered the home 1 hour after application was complete to open the windows and then he left. His family re-entered the home 2 days after product application and stayed the night. The family developed symptoms that night. The product was completely dry at the time of re-entry but the dry residue was evident and touched. The reporter states that everybody in his family including himself (Subform II #1) and his wife (Subform II #2) as well as his (age) year old (Subform II #4), (age) year old (Subform II #5) and (age) year old (Subform II #3) children developed throat irritation and itchy and burning skin; especially under the eyes. The callers (age) year old daughter also developed red skin under her eyes and her chest felt heavy. The following day the family was outside most of the day and the symptoms resolved but when they went back inside that evening the symptoms returned. 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: >6 <=12 yrs / > 6 < = 12 ans
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Paresthesia
- Symptom - Itchy skin
- Gastrointestinal System
- Symptom - Irritated throat
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Unknown
6. a) Was the person hospitalized?
Unknown
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? Normal daily activities
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.)
1-38588326 - The reporter, a home owner, indicated that his family was exposed to a registrant insecticide containing the active ingredient Lambda-cyhalothrin and to a non-registrant product called Bedlam containing unknown active ingredients. The reporter stated that the product was applied in his secondary home by a pest control operator to treat bedbugs five days prior to initial contact with the registrant. It took the PCO 6 hours to apply the product. The callers family was not in the home during application. The caller quickly re-entered the home 1 hour after application was complete to open the windows and then he left. His family re-entered the home 2 days after product application and stayed the night. The family developed symptoms that night. The product was completely dry at the time of re-entry but the dry residue was evident and touched. The reporter states that everybody in his family including himself (Subform II #1) and his wife (Subform II #2) as well as his (age) year old (Subform II #4), (age) year old (Subform II #5) and (age) year old (Subform II #3) children developed throat irritation and itchy and burning skin; especially under the eyes. The callers (age) year old daughter also developed red skin under her eyes and her chest felt heavy. The following day the family was outside most of the day and the symptoms resolved but when they went back inside that evening the symptoms returned. No further information is available.
To be determined by Registrant
14. Severity classification.
Minor
