Health Canada
Symbol of the Government of Canada
Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-0196

2. Registrant Information.

Registrant Reference Number: ProPharma Group case #: 1-46735646

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.

04-JAN-17

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

04-JAN-17

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. 8661      PMRA Submission No.       EPA Registration No.

Product Name: GRAMOXONE LIQUID HERBICIDE WITH WETTING AGENT

  • Active Ingredient(s)
    • PARAQUAT

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: Female

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

3. List all symptoms, using the selections below.

System

  • Eye
    • Symptom - Pain
    • Symptom - Dry eye
    • Symptom - Blurred vision

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

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.

Eye

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.)

1-46735646 - The reporter indicates an exposure to an herbicide containing the active ingredient paraquat. On the day of initial contact with the registrant, the reporter indicated she got a single drop of the diluted product in her right eye. The reporter indicated she had rinsed the eye for about 15 minutes, but the eye is painful and feels dry. The reporter was advised that a diluted solution of the product may result in irritation, but damage was not expected. If the symptoms persist, the reporter was advised to seek medical attention. The reporter was not available on follow-up call one day later. On follow-up two days later, the reporter indicated her vision was blurry for a few hours and she had sought medical attention, but the doctor did not see any damage to her vision. The reporter was advised to seek medical attention from an ophthalmologist to ensure no ocular damage is observed. No additional information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.