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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2024-1406

2. Registrant Information.

Registrant Reference Number: ProPharma Group case #: 2024SCPU00077968

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: MONTANA

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. Unknown

Product Name: DIQUAT

• Active Ingredient(s)
  • DIQUAT, PRESENT AS DIBROMIDE
    • Unknown

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: Res. - Out Home / Rés - à l'ext.maison

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.

Data Subject

2. Demographic information of data subject

Sex: Female

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Cardiovascular System
  • Symptom - Abnormally fast heart rate

• Respiratory System
  • Symptom - Coughing

• Gastrointestinal System
  • Symptom - Nausea
  • Symptom - Other
  • Specify - Gastrointestinal ulceration
  • Symptom - Other
  • Specify - Loss of epithelium in esophagus
  • Symptom - Stomach pain
  • Symptom - Other
  • Specify - Bleeding down entire gut

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?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Drift from the application site

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

10. Route(s) of exposure.

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.)

2024SCPU00077968- The reporter, the patient, indicates a suspected exposure to a pesticide containing the active ingredient diquat. The reporter indicated they suspect the product has been intentionally and maliciously misapplied near their house every few days for the past three years. The reporter indicated when the spraying occurs they get a rapid heart rate, coughing, and nausea. Over the past three years they have also experienced gastrointestinal ulcerations, loss of epithelium in their esophagus, stomach pains, and bleeding down their entire gut. The caller has sought medical attention but has not been hospitalized. The reporter indicated their GI doctor does not know the cause of these symptoms. The reporter was advised that the symptoms were not consistent with exposure to this pesticide as described and they should continue to receive symptomatic and supportive medical attention. No additional information is available

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.