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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-2040
2. Registrant Information.
Registrant Reference Number: ProPharma Group case #: 1-47755482
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.
08-APR-175. Location of incident.
Country: CANADA
Prov / State: ONTARIO
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.
Active(s)PMRA Registration No. PMRA Submission No. EPA Registration No. 100-1097
Product Name: KARATE INSECTICIDE WITH ZEON TECHNOLOGY
- Active Ingredient(s)
- LAMBDA-CYHALOTHRIN
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Res. - In Home / Rés. - à l'int. maison
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 - Swollen eye
- Symptom - Dry eye
- Symptom - Irritated eye
- Respiratory System
- Symptom - Irritated nose
- Symptom - Irritated throat
- Symptom - Coughing
- Skin
- Symptom - Rash
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Unknown
6. a) Was the person hospitalized?
Unknown
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Contact with treated area
What was the activity? Returning to living area after treatment
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
Eye
Respiratory
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.)
1-47755482 - The reporter, a home owner, indicates an exposure to a pesticide containing the active ingredient lambda-cyhalothrin. Five days before the day of initial contact with the registrant, the reporter indicated her home was sprayed with the product. The reporter stated she did not re-enter the dwelling until three days before the day of initial contact. The first morning that she awoke in her home upon re-entering after the application, she had swollen, irritated and dry eyes; her nose and throat were irritated; she had a cough; and a rash on her knees and foot. The reporter was advised that no symptoms would be anticipated after exposure to the dried product, but the reporter might have an unknown sensitivity to an ingredient in the product. If the symptoms continue, the reporter was advised to seek medical attention. The reporter was advised to thoroughly ventilate the home and wash down surfaces she may come in contact with. On follow-up call two days later, the reporter indicated she was feeling better. No additional information is available.
To be determined by Registrant
14. Severity classification.
Minor
