Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-4635

2. Registrant Information.

Registrant Reference Number: ProPharma Group case #: 1-53988547

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.

15-SEP-18

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

12-SEP-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. 24485      PMRA Submission No.       EPA Registration No. Unknown

Product Name: AVID 1.9% EC MITICIDE INSECTICIDE

• Active Ingredient(s)
  • ABAMECTIN

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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: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: unknown

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

• Gastrointestinal System
  • Symptom - Mouth Irritation

• Skin
  • Symptom - Other
  • Specify - acne

• Respiratory System
  • Symptom - Difficulty Breathing
  • Symptom - Nasal congestion

• General
  • Symptom - Lightheadedness

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

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)

Application

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

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.)

1-53988547 - The reporter indicates an exposure to a pesticide containing the active ingredient abamectin. Five days before the day of initial contact with the registrant, the reporter indicated he applied the product for the first time without wearing personal protective equipment. Three days before the day of initial contact, the reporter indicated he developed sores in his mouth and acne. On the day of initial contact, the reporter indicated he had used the product an additional two times and his symptoms continued to worsen in addition to developing nasal congestion, lightheadedness, and difficulty breathing. The reporter was advised that the symptoms would not be typical for an exposure to the product but discontinue use and seek medical attention for his symptoms due to their persistence. No additional information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.