Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-3427
2. Registrant Information.
Registrant Reference Number: ProPharma Group case #: 1-48776941
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.
28-JUN-17
5. Location of incident.
Country: CANADA
Prov / State: SASKATCHEWAN
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. 29138
PMRA Submission No.
EPA Registration No.
Product Name: BROADBAND HERBICIDE
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: 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.
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
- Nervous and Muscular Systems
- Symptom - Headache
- Symptom - Confusion
- Symptom - Sleepiness
- Symptom - Muscle weakness
- Symptom - Memory loss
- Blood
- Symptom - Other
- Specify - elevated hemoglobin
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
Unknown
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)
Respirator
10. Route(s) of exposure.
Skin
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.)
1-48776941 - The reporter, a farmer, indicates an exposure to a pesticide containing the active ingredients pinoxaden and florasulam. An unknown number of days before the day of initial contact with the registrant, the reporter indicated he was using the diluted product and almost immediately got a headache. Before proceeding, the reporter indicated he started using a respirator, but an unknown amount of time later he developed muscle weakness, confusion, sleepiness, and memory loss. Fifteen days before the day of initial contact, the reporter sought medical evaluation where he was diagnosed with elevated hemoglobin. The reporter was advised that his persistent symptoms would not be expected from the exposure and to continue to work with his doctor to find the cause of the symptoms. No follow-up was attempted. No additional information is available.
To be determined by Registrant
14. Severity classification.
Moderate
15. Provide supplemental information here.