Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2016-7842
2. Registrant Information.
Registrant Reference Number: ProPharma Group case #: 1-45960889
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.
17-OCT-16
5. Location of incident.
Country: CANADA
Prov / State: SASKATCHEWAN
6. Date incident was first observed.
17-OCT-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)
PMRA Registration No. 31058
PMRA Submission No.
EPA Registration No.
Product Name: REGLONE ION
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).
Site: Unknown / Inconnu
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: Male
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
4. How long did the symptoms last?
>2 hrs <=8 hrs / > 2 h < = 8 h
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
Occupational
8. How did exposure occur? (Select all that apply)
Other
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.
Skin
11. What was the length of exposure?
<=15 min / <=15 min
12. Time between exposure and onset of symptoms.
<=30 min / <=30 min
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.)
1-45960889 - The reporter indicates a co-worker had an exposure to a pesticide containing the active ingredient diquat. On the day of the initial contact with the registrant, the reporter indicated his co-worker was exposed to the product after it leaked from the top of a container. Some of the concentrated product got onto a two centimeter area of the skin on his hand. The co-worker immediately rinsed the area with soap and water, but is experiencing tingling in the area. The reporter was advised that brief dermal contact might cause irritation, but a systemic toxicity is not anticipated from dermal contact on intact skin. The reporter was advised to have the co-worker to seek medical attention should the symptom persist. On follow-up one day later, the co-worker indicated the symptom lasted about six hours. No additional information is available.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.