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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-6717

2. Registrant Information.

Registrant Reference Number: PROSAR Case 1-15231718

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: TENNESSEE

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. 100-956

Product Name: Centric - EPA:

  • Active Ingredient(s)
      • Unknown

7. b) Type of formulation.


Application Information

8. Product was applied?


9. Application Rate.


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).

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.


  • Nervous and Muscular Systems
    • Symptom - Muscle weakness
    • Symptom - Difficulty getting up
    • Symptom - Muscle pain

4. How long did the symptoms last?

>2 mos and <=6mos />2 mois et <=6mois

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.

>24 hrs <=3 days / >24 h <=3 jours

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 states his (age) old father applied the product without gloves on approximately 6-25-07, states "would have the powder on hands, for sure knew he inhaled some of the dust." On approximately 6-27-07 observed he was "real feeble, started in upper neck/back, now in buttocks / hips, now he can't get out of bed anymore." Patient has no medical history, caller states this "hit him all of a sudden." Has seen 2 Health Car Providers, one of which diagnosed the patient with polymyalgia. Symptoms continue to progress at this time. Assessment: - Would not expect the SX described to result from an exposure to this product. - Inhalation - Practically Non-Toxic - A respirator is not normally required when handling this substance - Skin - Moderately Irritating - It is recommended that gloves be worn when handling this products. - Recommended the caller's father to follow-up with his attending HCP's for treatment. - Case # given, encouraged to call back with any additional questions.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.

This product is not a powder, it is a WG. Precautions were not followed according to label instructions. This product is used specifically for spraying and there is no indication in report of spraying.