Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-5651

2. Registrant Information.

Registrant Reference Number: PROSAR Case 1-15075113

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

Address: 410 Swing Road

City: Greensboro

Prov / State: North Carolina

Country: USA

Postal Code: 27419

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

05-JUL-07

5. Location of incident.

Country: UNITED STATES

Prov / State: LOUISIANA

6. Date incident was first observed.

03-JUL-07

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.

Product Name: Atrazine

• Active Ingredient(s)
  • ATRAZINE (PLUS RELATED ACTIVE TRIAZINES)
    • Unknown

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7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Other / Autre

Préciser le type: Bayou Area

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?

No

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

• Respiratory System
  • Symptom - Shortness of breath

• Nervous and Muscular Systems
  • Symptom - Muscle tremors
  • Symptom - Headache

• Gastrointestinal System
  • Symptom - Anorexia

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

Non-occupational

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

Application

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.

<=30 min / <=30 min

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.)

Caller's father applied product on top of gasoline to treat a bayou on his property in [LOCATION]. This occurred on 7/3, he was working alone, and he was taken to local HCF in [LOCATION] where he was treated for SOB, "shakiness", HA. There he was tested with EKG and CT, and treated with steroids which have improved his breathing. Other symptoms are about the same, according to caller, and because HCPs are stymied, her father is being transferred to [LOCATION] for further eval and treatment. He is also inappetite, according to caller. He has asthma history. ASSESS: It would be helpful to establish name of product, and amt and concentration used. Length of exposure and pre-existing med history suggest likelihood of pulmonary complications secondary to described insults. Other symptoms may be secondary to this, or may have unassociated etiology. Called back and informed daughter that the "toxic combustion gases" are of no greater order than the gases rendered by combustion of gasoline. 07/07/07 Follow-Up Spoke with Daughter. She states that she just arrived at the HCF several hr ago and is still trying to establish what's going on with her father. He was just recently moved to ICU. CB not returned.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

The symptoms appear not to be consistent with the use of Atrazine. This product is not a registered use in Canada. It also does not appear to be a registered use in the US.