Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-3364
2. Registrant Information.
Registrant Reference Number: ProPharma Group case #: 1-48679582
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-JUN-17
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
20-JUN-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
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
4. How long did the symptoms last?
>24 hrs <=3 days / >24 h <=3 jours
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)
Application
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 <=2 hrs / >15 min <=2 h
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.)
1-48679582 - The reporter, a farm worker, indicates an exposure to a pesticide containing the active ingredient paraquat. On the day of initial contact with the registrant, the reporter indicated he was using the diluted product in a backpack sprayer which leaked onto his back. The reporter indicated the diluted product was in contact with his skin for about 1 hour and now he had developed skin irritation in the area. The reporter was advised to rinse the affected area with water and soap for at least 20 minutes, and seek medical attention if the symptom persisted. On follow-up call two days later, the reporter indicated his symptoms had resolved and he had not sought medical attention. No additional information is available.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.