Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-5943

2. Registrant Information.

Registrant Reference Number: PROSAR Case 1-15151965

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.

26-JUL-07

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

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.       PMRA Submission No.       EPA Registration No.

Product Name: Reward

• Active Ingredient(s)
  • DIQUAT
    • 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: Unknown / Inconnu

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Riding in an enclosed Cab

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

• Eye
  • Symptom - Other
  • Specify - Vision Changes

• Nervous and Muscular Systems
  • Symptom - Headache

• General
  • Symptom - Malaise

• Respiratory System
  • Symptom - Asthma

• Gastrointestinal System
  • Symptom - Stomach pain

4. How long did the symptoms last?

>6 mos / > 6 mois

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

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.

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.)

Adult male complaining of development of asthma, chronic headaches, abdominal pain, vision changes and loss of strength. States he works for company that sprays products, works in an enclosed cab. Has been working for company for last 6 years, has been complaining of symptoms for last 3 years. After discussion, caller is looking for information regarding use of PPE while in the enclosed cab - states there is nothing on label or MSDS (which he has in his possession) discussing his concerns.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.