Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-1462

2. Registrant Information.

Registrant Reference Number: ProPharma Group case #: 1-51466435

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.

23-FEB-18

5. Location of incident.

Country: UNITED STATES

Prov / State: ILLINOIS

6. Date incident was first observed.

23-FEB-18

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. 100-1431

Product Name: GRAMOXONE SL 2.0

• Active Ingredient(s)
  • PARAQUAT
    • Guarantee/concentration 30.1 %

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7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Unknown

9. Application Rate.

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.

Medical Professional

2. Demographic information of data subject

Sex: Male

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

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Tongue swelling

• General
  • Symptom - Pain

• Gastrointestinal System
  • Symptom - Other
  • Specify - throat is sloughing

• Respiratory System
  • Symptom - Other
  • Specify - Red bronchi on bronchoscopy

• Blood
  • Symptom - Anemia

• Renal System
  • Symptom - Creatinine increased

4. How long did the symptoms last?

>1 wk <=1 mo / > 1 sem < = 1 mois

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

8

Day(s) / Jour(s)

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.

Skin

Oral

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>24 hrs <=3 days / >24 h <=3 jours

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.)

1-51466435 - The reporter, a nurse, indicates an exposure to an herbicide containing the active ingredient paraquat. Two days before the day of initial contact with the registrant, the reporter indicated the patient was unhooking a hose on a delivery truck and some of the product sprayed on the patient¿¿¿¿¿¿s face and in his mouth. The patient was seen by a physician the same day, but did not have any symptoms and was released. On the day of initial contact with the registrant, the patient developed swelling of the tongue and was admitted to the ICU where he was sedated and intubated. One day after the day of initial contact, the patient¿¿¿¿¿¿s creatinine was slightly elevated, and he was put on intravenous pain medication. Three days after the day of initial contact, the patient¿¿¿¿¿¿s throat was sloughing. Four days after the day of initial contact, bronchoscopy of the patient¿¿¿¿¿¿s lungs revealed red bronchi, and the patient¿¿¿¿¿¿s creatinine was back to the normal range. Six days after the day of initial contact, the patient was transferred from ICU to normal hospitalization, and mild anemia was discovered on bloodwork. Seven days after the day of initial contact, the anemia was nearly resolved and the patient was discharged. No additional information is available.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.