Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-4953

2. Registrant Information.

Registrant Reference Number: PROSAR case number: 1-38529364

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.

23-SEP-14

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

18-SEP-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. 26396      PMRA Submission No.       EPA Registration No.

Product Name: Reglone Liquid Herbicide and Desiccant

• Active Ingredient(s)
  • DIQUAT

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7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Unknown / Inconnu

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

• Eye
  • Symptom - Conjunctival injection
  • Specify - Grade 2 injection temporal side

• Skin
  • Symptom - Other
  • Specify - Melting of the skin on the eyelid

• Eye
  • Symptom - Other
  • Specify - melting of sclera (3mm)

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?

No

6. b) For how long?

7. Exposure scenario

Unknown

8. How did exposure occur? (Select all that apply)

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.

Skin

Eye

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.)

1-38529364 - The reporter, a physician, indicated that an adult male was exposed to an herbicide containing the active ingredient diquat dibromide. The reporter stated that five days prior to initial contact with the registrant a (age)year old male got a splash of the product in his eye. The reporter thinks that it was the concentrated product that contacted the patients eye but he is not sure. At the time of the call, the reporter indicated that the patient is presenting with a grade 2 injection on the temporal side with melting (3mm patch) and some melting of the eyelid. The reporter further indicated that the melting involves the sclera and not the cornea. The reporter was advised that there are no reports of permanent eye damage in humans after exposure: Recovery from eye damage is expected to be complete with appropriate supportive care. No further information is available.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.