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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-3324

2. Registrant Information.

Registrant Reference Number: PROSAR case #: 1-41248744

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.

13-JUL-15

5. Location of incident.

Country: UNITED STATES

Prov / State: MISSOURI

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. 100-1282

Product Name: Halex GT

  • Active Ingredient(s)
    • GLYPHOSATE (PRESENT AS DIMETHYLAMINE SALT)
      • Guarantee/concentration 20.5 %
    • MESOTRIONE
      • Guarantee/concentration 2.05 %
    • S-METOLACHLOR AND R-ENANTIOMER
      • Guarantee/concentration 20.5 %

PMRA Registration No.       PMRA Submission No.       EPA Registration No. Unknown

Product Name: Unknown

  • Active Ingredient(s)
    • ATRAZINE (PLUS RELATED ACTIVE TRIAZINES)
      • Unknown

PMRA Registration No.       PMRA Submission No.       EPA Registration No. Unknown

Product Name: Unknown

  • Active Ingredient(s)
    • PARAQUAT
      • Unknown

7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Unknown

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 III: Domestic Animal Incident Report

1. Source of Report

Other

2. Type of animal affected

Dog / Chien

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

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

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.

Unknown

14. a) Was the animal hospitalized?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

16. How was the animal exposed?

Contact treat.area/Contact surf. traitée

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

1-41248744 - The reporter indicated that a co-workers dog may have been exposed to herbicides containing the active ingredient s-metolachlor, mesotrione, glyphosate, paraquat dichloride and atrazine. The reporter indicated that his co-worker lives 50-75 yards away from a field where, 1.5 months prior to initial contact with the registrant, there may have been drift from an aerial application of Halex GT and atrazine. The farmer applied the Halex GT and atrazine aerially to his corn field but the paraquat and round-up were applied by hand. The reporter does not believe drift from the paraquat and round-up would have reached the field near the co-workers home. Per the reporter the co-workers garden and grape vines died after the aerial application and 1.5 miles up the valley the leaves on the trees died. The co-worker also told the reporter that his dog died. The reporter did not have any additional information on the dog, what type of exposure the dog might have had, the onset of symptoms, if it had any symptoms prior to death, or if veterinary care was sought. No additional 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