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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-5668

2. Registrant Information.

Registrant Reference Number: PROSAR Case 1-15028636

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.


4. Date registrant was first informed of the incident.


5. Location of incident.


Prov / State: FLORIDA

6. Date incident was first observed.


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.

Product Name: Ridomil Gold EC - EPA: 100-801

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

7. b) Type of formulation.


Application Information

8. Product was applied?


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?


Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.


2. Demographic information of data subject

Sex: Male

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

3. List all symptoms, using the selections below.


  • Eye
    • Symptom - Other
    • Specify - Neovascular Glaucoma
    • Symptom - Burn on the eye

4. How long did the symptoms last?

Unknown / Inconnu

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


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


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)


10. Route(s) of exposure.


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.)

Caller works for an insurance company, researching a workman's comp. claim. Alleged exposure took place on 12-12-06, patient was using the Ridomil Gold EC and/or MBC 67-33 (non-company product), had some splash into eye resulting in Neovascular Glaucoma and "chemical burns on the eye." It is unknown when sx developed, but the caller believes, "there was a lapse of time." Per a medical report, the patient has a history of "underlying chronic glaucoma." Not known if exposure was to concentrated or diluted products. Caller states there is no information regarding whether a case had been created already or not, does not believe it was reported. Assessment - Unable to locate information regarding MBC 67-33, as it is a non-company product. - The Ridomil Gold EC is not corrosive, and may cause eye irritation, but would not be expected to cause burns or permanent tissue damage. - Unable to locate a pre-existing case.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.

Ridomil is not corrosive and may cause eye irritation, however, it will not be expected to cause burns and tissue damage.