Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-5667

2. Registrant Information.

Registrant Reference Number: PROSAR Case 1-14889423

Registrant Name (Full Legal Name no abbreviations): Syngenta Crop Protection 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.

11-MAY-07

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

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)

---

PMRA Registration No. 27833      PMRA Submission No.       EPA Registration No.

Product Name: CALLISTO 480SC HERBICIDE

• Active Ingredient(s)
  • MESOTRIONE

---

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

Product Name: Touchdown

• Active Ingredient(s)
  • GLYPHOSATE

---

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: Unknown / Inconnu

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

• Nervous and Muscular Systems
  • Symptom - Memory loss
  • Specify - forgetfulness

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Unknown

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

Contact with treated area

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.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>3 days <=1 wk / >3 jours <=1 sem

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.)

Husband has been working with products over the last week, Caller would like to know the side effects of inhaling products. Husband has become very forgetful in the last week. IE Leaving shower on, leaving burners on etc.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Symptoms described would not be typical of routine product use. Upon inhalation, may be irritating to the respiratory tract triggering sneezing, coughing, possible headache, but symptoms subside when removed from the source of the odor. Would not expect "forgetfulness" as described.