Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-5416

2. Registrant Information.

Registrant Reference Number: ProPharma Group case #: 1-45308902

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.

20-AUG-16

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

19-AUG-16

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)

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PMRA Registration No. 31058      PMRA Submission No.       EPA Registration No.

Product Name: REGLONE ION

• Active Ingredient(s)
  • DIQUAT

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7. b) Type of formulation.

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

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Red eye
  • Symptom - Irritated eye

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?

Unknown

6. b) For how long?

7. Exposure scenario

Unknown

8. How did exposure occur? (Select all that apply)

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.

Eye

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>8 hrs <=24 hrs / > 8 h < = 24 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.)

1-45308902- The reporter indicates an exposure to an herbicide containing the active ingredient diquat. Two days before initial contact with the registrant, the reporter accidently got some of the product concentrate in his eye. He rinsed his eye afterwards, but the next morning the eye was red and irritated. He sought medical attention one day before initial contact with the registrant where his eye was irrigated and he was sent home with medication. On the day of initial contact with the registrant, the reporter indicated his eyes were even more irritated. The reporter was advised to get his eyes rechecked by an ophthalmologist. On follow-up call two days later, the reporter indicated he had seen his doctor again who recommended another appointment with an ophthalmologist. No additional follow-up was attempted. No additional information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.