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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2021-1773

2. Registrant Information.

Registrant Reference Number: ADV1508

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: N1G 4Z3

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

26-MAR-21

5. Location of incident.

Country: UNITED STATES

Prov / State: ARIZONA

6. Date incident was first observed.

22-FEB-21

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)

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

Product Name: Unknown

  • Active Ingredient(s)
    • PARAQUAT
      • Unknown

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: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

  • Gastrointestinal System
    • Symptom - Other
    • Specify - Gastic erosion
    • Symptom - Other
    • Specify - Gastric inflammation
    • Symptom - Other
    • Specify - Gastritis
    • Symptom - Nausea
    • Symptom - Vomiting
  • General
    • Symptom - Death
    • Symptom - Other
    • Specify - Basal consolidation of lung
    • Symptom - Other
    • Specify - Grade D Esophagitis
    • Symptom - Other
    • Specify - Organ failure
    • Symptom - Other
    • Specify - Pleural thickening
  • Respiratory System
    • Symptom - Cyanosis
    • Symptom - Other
    • Specify - Respiratory depression
    • Symptom - Respiratory irritation
    • Symptom - Shortness of breath
    • Symptom - Other
    • Specify - Hypoxia
    • Symptom - Respiratory failure

4. How long did the symptoms last?

Persisted until death

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

11

Day(s) / Jour(s)

7. Exposure scenario

Non-occupational

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)

None

10. Route(s) of exposure.

Oral

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

Please refer to information submitted by Bayer CropScience Inc. (Registrant Ref. #2899356; submitted 2021-03-25) for additional details about the incident. This incident information has not been verified by Syngenta and is reported herein based on details directly provided by Bayer CropScience Inc.

To be determined by Registrant

14. Severity classification.

Death

15. Provide supplemental information here.

On March 26, 2021 Syngenta Canada Inc. was notified by Bayer CropScience Inc. that Bayer CropScience LLC(US) received a report of Glyphosate ingestion which, after investigation, they speculated was potentially an incident of Paraquat ingestion. The specific product was not identified in the report.Syngenta Canada submitted a letter to PMRA dated March 29, 2021 flagging Bayer submission of Registrant Ref. #2899356 and are now submitting a supplemental incident report on the same matter via 0.1.7003 form based on PMRA request of April 21, 2021 to do so.