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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-0571
2. Registrant Information.
Registrant Reference Number: PROSAR case #: 1-39480229
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.
16-JAN-155. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
14-JAN-15Product 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 Insecticide
- Active Ingredient(s)
- LAMBDA-CYHALOTHRIN
PMRA Registration No. 15255 PMRA Submission No. EPA Registration No.
Product Name: DRIONE INSECTICIDE DUST
- Active Ingredient(s)
- PIPERONYL BUTOXIDE
- PYRETHRINS
- SILICA AEROGEL
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: >64 yrs / > 64 ans
3. List all symptoms, using the selections below.
System
- Eye
- Symptom - Red eye
- Skin
- Symptom - Edema
- Eye
- Symptom - Irritated eye
4. How long did the symptoms last?
>3 days <=1 wk / >3 jours <=1 sem
5. Was medical treatment provided? Provide details in question 13.
No
6. a) Was the person hospitalized?
No
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? Daily living
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.
>2 hrs <=8 hrs / > 2 h < = 8 h
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.)
1-39480229 - The reporter, a home owner, indicated that both he and his wife had been exposed to a registrant insecticide containing the active ingredient Lambda-cyhalothrin and to a non-registrant insecticide (Drione Insecticide Powder) with unknown active ingredients. The pest control operator applied the products inside the reporters home during the morning two days prior to initial contact with the registrant. The reporter and his wife vacated the home during application and did not re-enter the home until late afternoon. That evening, the reporter and his wife began experiencing ocular irritation, redness and later they had some eyelid swelling. The reporter was advised that exposure to the fumes may cause transient ocular irritation and ventilation of the home was recommended. On follow-up call, three days later, the reporter indicated that the odor had dissipated and symptoms for both the reporter and his wife were improving. They had not sought medical attention. No additional 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: >64 yrs / > 64 ans
3. List all symptoms, using the selections below.
System
- Eye
- Symptom - Red eye
- Symptom - Irritated eye
- Skin
- Symptom - Edema
- General
- Symptom - Swelling
4. How long did the symptoms last?
>3 days <=1 wk / >3 jours <=1 sem
5. Was medical treatment provided? Provide details in question 13.
No
6. a) Was the person hospitalized?
No
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 living
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?
>2 hrs <=8 hrs / >2 h <=8 h
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.)
1-39480229 - The reporter, a home owner, indicated that both he and his wife had been exposed to a registrant insecticide containing the active ingredient Lambda-cyhalothrin and to a non-registrant insecticide (Drione Insecticide Powder) with unknown active ingredients. The pest control operator applied the products inside the reporters home during the morning two days prior to initial contact with the registrant. The reporter and his wife vacated the home during application and did not re-enter the home until late afternoon. That evening, the reporter and his wife began experiencing ocular irritation, redness and later they had some eyelid swelling. The reporter was advised that exposure to the fumes may cause transient ocular irritation and ventilation of the home was recommended. On follow-up call, three days later, the reporter indicated that the odor had dissipated and symptoms for both the reporter and his wife were improving. They had not sought medical attention. No additional information is available.
To be determined by Registrant
14. Severity classification.
Minor
