Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-3912

2. Registrant Information.

Registrant Reference Number: ProPharma Group case #: 1-53401918

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.

30-JUL-18

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

6. Date incident was first observed.

22-JUN-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. Unknown

Product Name: REGLONE ION

• Active Ingredient(s)
  • DIQUAT

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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.

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

• Eye
  • Symptom - Pain
  • Symptom - Red eye
  • Symptom - Irritated eye
  • Symptom - Swollen eye
  • Symptom - Other
  • Specify - unspecified damage to the surface of both eyes

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

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

Eye

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.)

1-53401918 - The reporter indicates an exposure to a pesticide containing the active ingredient diquat. On the day of initial contact with the registrant, the reporter indicated a line on a sprayer blew off and sprayed him in the face with an unknown dilution of the product. The reporter stated he was able to rinse the product off. The reporter was advised to thoroughly flush his eyes and skin as a strong solution might cause severe irritation to the eyes, and to seek medical attention if symptoms occur. One day after the initial day of contact, the reporter called back saying he had done additional rinsing of his eyes, but his eyes are red. The reporter indicated he had not sought medical evaluation due to long wait times at the emergency room. On follow-up two days after initial contact, the reporter indicated he had sought medical attention where they flushed his eyes and prescribed medication, but his eyes were painful and swollen. Three days after initial contact, the reporter called to say his symptoms were not improving. The reporter was advised to continue to follow his doctor's recommendations. Six and nine days after initial contact, the reporter was not available on follow-up call. On a follow up call eleven days after exposure, the reporter indicated his doctor said there was unspecified damage to the surface of both eyes. The reporter was encouraged to continue to follow his doctor's recommendations. No additional information is available.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.