Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2021-4497

2. Registrant Information.

Registrant Reference Number: ProPharma Group case #: 2021SCPC00022103

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.

16-AUG-21

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

6. Date incident was first observed.

04-AUG-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)

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PMRA Registration No. 31058      PMRA Submission No.       EPA Registration No.

Product Name: REGLONE ION

• Active Ingredient(s)
  • DIQUAT
    • Guarantee/concentration 200 g/L

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7. b) Type of formulation.

Application Information

8. Product was applied?

No

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 - Irritated eye
  • Symptom - Burning eye

• Skin
  • Symptom - Burns (2nd or 3rd degree)

• Eye
  • Symptom - Blindness (permanent)

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?

Yes

6. b) For how long?

Unknown

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.

Eye

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>2 hrs <=8 hrs / > 2 h < = 8 h

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.)

2021SCPC00022103- The reporter indicates an exposure to a pesticide containing the active ingredient diquat. Twelve days before the day of initial contact with the registrant, the reporter indicated their son got the pesticide sprayed in his eye while changing out a pump and immediately rinsed out the eye. The reporter stated his son experienced eye irritation and burning approximately five hours after the exposure, and an unknown amount of time later medical attention was sought where third-degree burns were diagnosed around the eye. Approximately ten or eleven days before the day of initial contact, the reporter indicated his son had surgery on the eye. An unknown amount of time before the day of initial contact, the son lost vision in the eye. No additional information is available.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.