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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-5193
2. Registrant Information.
Registrant Reference Number: PROSAR case #: 1-41877800
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-SEP-15
5. Location of incident.
Country: UNITED STATES
Prov / State: CALIFORNIA
6. Date incident was first observed.
13-SEP-15
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. 100-1323
Product Name: Heritage G
- Active Ingredient(s)
- AZOXYSTROBIN
- Guarantee/concentration .31 %
7. b) Type of formulation.
Dust
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 III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Fish / Poisson
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
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
No
14. a) Was the animal hospitalized?
No
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
16. How was the animal exposed?
Other / Autre
specify Child poured the powder in the fish tank
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1-41877800 - The reporter indicated that some fish were exposed to a fungicide containing the active ingredient azoxystrobin. The reporter stated that her 2 year old son got ahold of the product container and poured the powder in the fish tank earlier on the day of initial contact and at the time of the initial call all the fish had died. The reporter did not provide additional information on the type or number of fish that were affected. No further 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