Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-4270

2. Registrant Information.

Registrant Reference Number: ProPharma Group case #: 1-52379944

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.

13-MAY-18

5. Location of incident.

Country: UNITED STATES

Prov / State: ALABAMA

6. Date incident was first observed.

13-MAY-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: 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?

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

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Tongue swelling
  • Symptom - Other
  • Specify - Swollen lips and throat

• Renal System
  • Symptom - Creatinine increased

• Gastrointestinal System
  • Symptom - Other
  • Specify - Blistering in the mouth

• Liver
  • Symptom - Hyperbilirubinemia

• Gastrointestinal System
  • Symptom - Drooling

• Blood
  • Symptom - Other
  • Specify - electrolytes increased

• Renal System
  • Symptom - Dialysis required

• Respiratory System
  • Symptom - Other
  • Specify - airway swelling
  • Symptom - Other
  • Specify - hypoxia

• Gastrointestinal System
  • Symptom - Difficulty swallowing
  • Specify - inability to swallow

• Blood
  • Symptom - Blood urea nitrogen increased

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?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

Occupational

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

Pesticide Spill

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.

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.)

1-52379944 - The reporter, a medical health professional, indicates an exposure to an herbicide containing the active ingredient paraquat. One day before the day of initial contact with the registrant, the reporter indicated a hose blew on a machine and the concentrated product was sprayed in the patient's face, chest and mouth. The patient rinsed out his mouth immediately, but was not able to shower to remove the product from his skin for approximately 40 minutes. On the day of initial contact, the patient's lips, tongue, and throat were swollen and he was hospitalized. Two days after the day of initial contact, the patient's condition was about the same. Three days after the day of initial contact, the patient was intubated due to airway swelling, and a small amount of oxygen was given due to hypoxia. The patient's creatinine level and total bilirubin levels were elevated, he had blistering inside his mouth, and he was drooling due to inability to swallow. Four days after the day of initial contact with the registrant, the patient's creatinine continued to increase and the blood urea nitrogen was elevated. Five days after the day of initial contact, the patient was placed on kidney dialysis, his creatinine and blood urea nitrogen continued to increase, and his electrolytes were increased. Six days after the day of initial contact, the patient's family requested that no further updates be provided to the registrant. No additional information is available.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.