Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-3365

2. Registrant Information.

Registrant Reference Number: ProPharma Group case #: 1-48898431

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-JUL-17

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

08-JUL-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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. Unknown

Product Name: GRAMOXONE

• Active Ingredient(s)
  • PARAQUAT

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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).

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.

Medical Professional

2. Demographic information of data subject

Sex: Male

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Death

• Gastrointestinal System
  • Symptom - Vomiting
  • Symptom - Stomach pain

• Nervous and Muscular Systems
  • Symptom - Unconsciousness

4. How long did the symptoms last?

Persisted until death

5. Was medical treatment provided? Provide details in question 13.

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

Unknown

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

Poisoning from ingestion of the pesticide

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.

Oral

11. What was the length of exposure?

Unknown / Inconnu

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.)

1-48898431 - The reporter, a physician, indicates an exposure to a pesticide containing the active ingredient paraquat. On the day of initial contact with the registrant, the reporter indicated the patient had ingested a drinking cup of the concentrate of the product about 30 minutes prior to the call. The patient had at one point been unconscious, but was currently vomiting and having abdominal pain. The reporter was advised and revised medical information was given to support the treatment and care of the patient On follow-up call one day later, the reporter indicated the patient had died during the evening on the day of initial contact with the registrant. No additional information is available.

To be determined by Registrant

14. Severity classification.

Death

15. Provide supplemental information here.

The exact product identity has not been confirmed, as no product container or product label was found.