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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-0371

2. Registrant Information.

Registrant Reference Number: ProPharma Group case #: 2023SCPU00063896

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: UNITED STATES

Prov / State: WISCONSIN

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.       PMRA Submission No.       EPA Registration No. 100-1610

Product Name: FORCE EVO

• Active Ingredient(s)
  • TEFLUTHRIN
    • Guarantee/concentration 24.2 %

7. b) Type of formulation.

Liquid

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.

Medical Professional

2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Irritated skin

• Respiratory System
  • Symptom - Coughing
  • Symptom - Other
  • Specify - Right lower lung lesion
  • Symptom - Shortness of breath

• Gastrointestinal System
  • Symptom - Weight loss

• General
  • Symptom - Sweating
  • Symptom - Fatigue

• Respiratory System
  • Symptom - Other
  • Specify - Cavitary lung lesion

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

Unknown

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

Respiratory

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.)

2023SCPU00063896- The reporter, a health care professional, indicates an exposure to a pesticide containing the active ingredient tefluthrin. Twenty-one months before the day of initial contact with the registrant, the reporter indicated the patient was splashed in the face with the product causing inhalation, dermal, and ocular exposures. The patient presented to the emergency department where he was instructed to rinse thoroughly and apply vitamin E oil to the skin. The patient developed minor skin irritation which soon subsided. Ten months before the day of initial contact with the registrant, the patient developed a cough and radiographs showed a right lower lung lesion. Over an unspecified length of time the patients cough worsened and he developed shortness of breath, weight loss, night sweats and generalized fatigue. On the day of initial contact the reporter indicated the patient was intubated in the ICU and radiographs showed a cavitary lung lesion. On follow-up calls two, three and six days after the day of initial contact, the reporter was not available. No additional information is available.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.