Print | Need Larger Text?

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-5874

2. Registrant Information.

Registrant Reference Number: Prosar 1-16702023

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.

5. Location of incident.

Country: CANADA

Prov / State: UNKNOWN

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.

PMRA Registration No. 26509      PMRA Submission No.       EPA Registration No.

Product Name: Prelude 240

• Active Ingredient(s)
  • PERMETHRIN

7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

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.

Other

2. Demographic information of data subject

Sex: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Nausea

• 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.

Unknown

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)

Other

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.

Unknown

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.)

1-16702023: A reporter (customer service representative) called on 10/02/2008 to relay a report from a female subject who had an exposure to an insecticide containing the active ingredient Permethrin. The female subject called the company's customer service line to report that she had had exposure to the product in the week prior to her report. According to the reporter, the product may have been used on a road close to the female subject's home. The female subject developed signs of nausea, headache, and dizziness. She was seen by her physician who said that she was fine. At the time of the female subject's report to customer service, she was asymptomatic. The reporter was advised that the information would be documented. A recommendation was made to have callers with medical concerns contact the health and safety line directly for assistance. NOTE: The details of exposure, including route and time frame, are unknown.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

The details of exposure, including route and time frame, are unknown. Exposure to high vapor levels may cause headache, dizziness, and nausea.