Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-7064

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-35535696

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.

Domestic Animal

4. Date registrant was first informed of the incident.

18-NOV-13

5. Location of incident.

Country: UNITED STATES

Prov / State: NEBRASKA

6. Date incident was first observed.

18-NOV-13

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.       PMRA Submission No.       EPA Registration No. 100-941

Product Name: Cruiser 5FS

• Active Ingredient(s)
  • THIAMETHOXAM
    • Guarantee/concentration 47.6 %

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 100-1352

Product Name: Maxim Quattro

• Active Ingredient(s)
  • AZOXYSTROBIN
    • Guarantee/concentration 1.33 %
  • FLUDIOXONIL
    • Guarantee/concentration 3.32 %
  • METALAXYL-M (MEFENOXAM)
    • Guarantee/concentration 2.65 %
  • THIABENDAZOLE
    • Guarantee/concentration 26.5 %

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7. b) Type of formulation.

Other (specify)

Seed corn coated with these products

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 III: Domestic Animal Incident Report

1. Source of Report

Medical Professional

2. Type of animal affected

Dog / Chien

3. Breed

Mixed Breed

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

6

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• Nervous and Muscular Systems
  • Symptom - Ataxia

• General
  • Symptom - Death
  • Symptom - Polydipsia

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

No

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

16. How was the animal exposed?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

1-35535696 - The reporter, a veterinarian, indicated that a dog was exposed to corn seeds which had been treated with the active ingredients thiamethoxam, thiabendazole, fludioxonil, metalaxyl-m and azoxystrobin. The reporter indicated that sometime either overnight or on the morning of initial contact with the registrant a 6 year old, female mixed breed dog ingested approximately 1-2 cups of treated corn and an unknown amount of non-registrant mouse poison with unknown active ingredients. At the time of the initial call the veterinarian had not yet seen the dog but was told by the pet owner that the dog was ataxic. On follow-up call, three days later, the reporter indicated that the pet owner declined to bring the dog to the veterinary clinic and it passed away at home without any veterinary care. The pet owner reported that prior to its death the dog was very thirsty and ataxic. The reporter also stated that the dog could have gotten into the registrant treated corn, non-registrant mouse poison or antifreeze and the cause for the dogs symptoms and death were unknown. No further information is available.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here