Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2014-5680
2. Registrant Information.
Registrant Reference Number: PROSAR case #: 1-39013162
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.
14-NOV-14
5. Location of incident.
Country: CANADA
Prov / State: ALBERTA
6. Date incident was first observed.
12-NOV-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)
PMRA Registration No.
PMRA Submission No.
EPA Registration No. Unknown
Product Name: Gramoxone
7. b) Type of formulation.
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.
Other
2. Demographic information of data subject
Sex: Male
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Gastrointestinal System
- Symptom - Nausea
- Symptom - Vomiting
- Nervous and Muscular Systems
- Blood
- Symptom - Hypoxemia
- Specify - Hypoxia
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
Non-occupational
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.)
1-39013162 - The reporter, a clinical toxicologist at the University of (name), indicated that an (age) year old male was exposed to an herbicide containing the active ingredient Paraquat. The reporter stated that about (age) years ago the product had been placed in a whiskey bottle and a piece of tape had been placed on the bottle with the word Gramoxone handwritten on it. The original product container was no longer available and additional product information including the product registration number could not be provided. Two days prior to initial contact with the registrant, the patient, thinking that he was drinking whiskey, took one swig of the product. The initial reporter did not have additional information on the exposure but on follow-up call to the Alberta poison control the following information is provided: Following the exposure the patient initially developed nausea and vomiting followed by confusion and drowsiness. He then developed hypoxia and on the day of the initial call the patient was intubated and was receiving treatment in the ICU. On follow-up call, later the same day, the Alberta poison control indicated that the patient had passed away. No additional information is available.
To be determined by Registrant
14. Severity classification.
Death
15. Provide supplemental information here.