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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-3279

2. Registrant Information.

Registrant Reference Number: ProPharma Group case #: 1-56849812

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.


4. Date registrant was first informed of the incident.


5. Location of incident.


Prov / State: FLORIDA

6. Date incident was first observed.


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.


PMRA Registration No.       PMRA Submission No.       EPA Registration No. Unknown


  • Active Ingredient(s)
      • Unknown

7. b) Type of formulation.


Application Information

8. Product was applied?


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?


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: Female

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

3. List all symptoms, using the selections below.


  • Gastrointestinal System
    • Symptom - Nausea
    • Symptom - Vomiting
  • Skin
    • Symptom - Lesion
    • Specify - small scab around patient's mouth
  • Gastrointestinal System
    • Symptom - Irritated throat
  • Renal System
    • Symptom - Creatinine increased
  • Respiratory System
    • Symptom - Tachypnea
    • Symptom - Shortness of breath
  • Blood
    • Symptom - Other
    • Specify - decreased oxygen saturation
  • Renal System
    • Symptom - Dialysis required
  • Respiratory System
    • Symptom - Other
    • Specify - Intubation required

4. How long did the symptoms last?

Unknown / Inconnu

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


6. a) Was the person hospitalized?


6. b) For how long?


7. Exposure scenario


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

Poisoning from ingestion of the pesticide

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)


10. Route(s) of exposure.


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.)

1-56849812 The reporter, a medical professional, indicates an exposure to an herbicide containing the active ingredient paraquat. On the morning of the day of initial contact with the registrant, the reporter indicated a x-year-old female patient drank one to two sips of the concentrated product from a beverage bottle that her husband had used to transport the concentrate home from work. An unknown amount of time later, the patient experienced nausea and vomiting and was transported to an emergency room. The reporter was advised that the product is highly toxic with effects to the gastrointestinal tract and multi-organ failure. On follow-up call eight hours after the time of initial contact, the reporter indicated the patient was in the ICU and had received dialysis. On follow-up call one day after the day of initial contact, the reporter indicated the patient had again received dialysis and had a small scab around her mouth. On follow-up call three days after the day of initial contact, the patient was still receiving dialysis, had mild throat discomfort, and had been intubated. On follow-up call five days after the day of initial contact, the reporter indicated they were seeing a mild creatinine elevation, dialysis continued, and the patient continued to be intubated due to tachypnea, shortness of breath, and decreased oxygen saturation. On follow-up call eight days after the day of initial contact, the reporter indicated the patient was still intubated and on daily dialysis. On follow-up call ten days after the day of initial contact, the reporter indicated the patient was still intubated, on daily dialysis and was getting a feeding tube placed. On follow-up call twelve days after the day of initial contact, the reporter indicated the patient was stable and being transferred out of the ICU. The reporter indicated no additional information could be provided. No additional information is available.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.