Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2020-5161

2. Registrant Information.

Registrant Reference Number: ProPharma Group case #: 1-62078775

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.

26-AUG-20

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

24-AUG-20

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. 31058      PMRA Submission No.       EPA Registration No.

Product Name: REGLONE ION

• Active Ingredient(s)
  • DIQUAT

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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.

Other

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 - Dry eye

• Skin
  • Symptom - Dry skin
  • Symptom - Blister

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)

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.)

1-62078775 - The reporter indicates an exposure to a pesticide containing the active ingredient diquat. Two days before the day of initial contact, the reporter indicated her husband got a few drops of the concentrated pesticide on his lips and the corner of his right eye while loading it onto a tractor. The reporter stated her husband immediately wiped off the pesticide and showered within an hour of exposure, but his lips felt dry immediately. On the day of initial contact, the reporter indicated her husband had developed a blister on his lip and his eye felt dry, so they were seeking medical attention. The reporter was advised to have the medical personnel evaluate both exposure sites, but a toxicity was not expected. The reporter was not available on follow up call four and five days after the day of initial contact. No additional information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.