Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2021-4496

2. Registrant Information.

Registrant Reference Number: ProPharma Group case #: 2021SCPC00017886

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.

01-OCT-20

5. Location of incident.

Country: CANADA

Prov / State: PRINCE EDWARD ISLAND

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.

Active(s)

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PMRA Registration No. 31050      PMRA Submission No.       EPA Registration No.

Product Name: STADIUM FUNGICIDE

• Active Ingredient(s)
  • AZOXYSTROBIN
    • Guarantee/concentration 143 g/L
  • DIFENOCONAZOLE
    • Guarantee/concentration 112 g/L
  • FLUDIOXONIL
    • Guarantee/concentration 143 g/L

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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: Potatoes

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

2021SCPC00017886 - The patient was applying the pesticide to post-harvest potatoes on a bin piler line.

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

• General
  • Symptom - Malaise

4. How long did the symptoms last?

Unknown / Inconnu

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

No

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)

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.

Unknown

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.)

2021SCPC00017886 - The reporter, a registrant representative, indicates an exposure to a pesticide containing the active ingredients fludioxonil, azoxystrobin, and difenoconazole. On the day of initial contact with the registrant, a man advised the reporter that he had an unspecified exposure to the pesticide during application. An unknown amount of time after exposure the man stated he felt off, but he never sought medical attention and did not specify how long his symptoms lasted. No additional information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.