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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2007-5942
2. Registrant Information.
Registrant Reference Number: PROSAR Case 1-15143864
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.
25-JUL-075. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
22-JUL-07Product 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. 24984 PMRA Submission No. EPA Registration No.
Product Name: Matador 120EC Emulsifiable Concentrate Insecticide
- Active Ingredient(s)
- CYHALOTHRIN-LAMBDA
7. b) Type of formulation.
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 II: Human Incident Report (A separate form for each person affected)
1. Source of Report.
Data Subject
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 - Headache
- Symptom - Dizziness
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
Unknown
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.
Skin
11. What was the length of exposure?
<=15 min / <=15 min
12. Time between exposure and onset of symptoms.
>8 hrs <=24 hrs / > 8 h < = 24 h
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.)
History: Caller was accidentally sprayed with the product on Sunday (7/22). He was underneath the sprayer and the switch was on. The product was sprayed on his hair and a little on his face. The next morning when he got out of bed he was very dizzy and his mind was spinning inside his head. He has also had a headache off and on. He has been into his family doctor but did not tell her about the product exposure. She prescribed =betahistine for the symptoms. If he doesn't take the medication the symptoms return, he believes that the medication is not working Wondering if the product could have entered his system through his eyes, he did not have goggles on and never developed ocular irritation. Wondering if we will report him and take away his pesticide license for this? Assessment: - Product has a low level of toxicity and the exposure you described is not expected to cause the listed symptoms - Dermal exposure can cause burning, numbness or tingling on the site and symptoms are expected to diminish on their own within 24 hours - Product Active Ingredient cannot enter the blood stream through the eyes. Ocular exposure can result in ocular irritation - Recommend continuing to follow up with a physician today if possible to discuss this further - If you or MD have additional questions / concerns about the product used please callback
To be determined by Registrant
14. Severity classification.
Minor
