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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2020-4481

2. Registrant Information.

Registrant Reference Number: ProPharma Group case #: 1-62035127

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.

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

Unknown

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. 31058      PMRA Submission No.       EPA Registration No. Unknown

Product Name: REGLONE ION

• Active Ingredient(s)
  • DIQUAT

7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

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 - Red eye
  • Symptom - Discharge eye

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?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

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.)

1-62035127- The reporter indicates an exposure to a pesticide containing the active ingredient diquat. Three days before the day of initial contact, the reporter indicated he got some of the concentrated pesticide on his eyelid and around his eye and immediately wiped it off but was unable to wash the area for several hours. An unknown amount of time later the eye became red and produced a discharge. The reporter was advised to seek immediate medical evaluation as severe irritation can occur. On follow-up call three days later, the reporter indicated he sought medical attention, was prescribed medication, and the eye was improving. No additional information is available.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.