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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-5184

2. Registrant Information.

Registrant Reference Number: PROSAR case #: 1-41858106

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.

5. Location of incident.

Country: UNITED STATES

Prov / State: KANSAS

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.

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

Product Name: Unknown

• Active Ingredient(s)
  • PARAQUAT
    • Unknown

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: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Stomach pain
  • Symptom - Melena
  • Symptom - Other
  • Specify - Gastric reflux

• Skin
  • Symptom - Burns (superficial)
  • Specify - Esophageal burns

• Gastrointestinal System
  • Symptom - Other
  • Specify - Esophageal stricture
  • Symptom - Sore throat
  • Symptom - Other
  • Specify - Gall bladder removed

• Respiratory System
  • Symptom - Difficulty Breathing

• General
  • Symptom - Lethargy

• Gastrointestinal System
  • Symptom - Vomiting
  • Symptom - Diarrhea

• Nervous and Muscular Systems
  • Symptom - Fainting

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?

Yes

6. b) For how long?

Unknown

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.)

1-41858106 - The reporter indicated that his adult daughter may have been exposed to an herbicide containing the active ingredient paraquat. There was no witnessed exposure to paraquat but the reporter was concerned that his daughters estranged husband (at the time of the call they were in the process of a divorce) had been poisoning his daughter and based on her symptoms it was thought her husband might have been using paraquat. This concern had not yet been relayed to the police but the reporter indicated that his son-in-law was the sole beneficiary of a $500,000.00 life insurance policy that had been taken out on his wife. The reporter did not know how his son-in-law would have gained access to paraquat; there were no known containers of the product in the household and his son-in-law worked as a radiologist and did not have ready access to the product. The reporter indicated that for the past year his daughter has been intermittently sick. Six months prior to initial contact with the registrant she had her gallbladder removed. She has been diagnosed with gastric reflux, esophageal burns, and esophageal strictures. She has severe stomach pain and at the time of the call her stools were black and tarry. She also has had difficulty breathing and her energy level is minimal. Six months ago she was tested for arsenic exposure and those results were negative. The reporter was advised that chronic toxicities are not commonly seen with paraquat exposures but there is testing available to help determine if his daughter had been exposed to paraquat. Four days later, the patient called and in addition to the above symptoms the patient also stated that she has had intermittent vomiting and diarrhea and fainting spells. She also indicated that the gastric reflux was first diagnosed in 2013. No additional information is available.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.