Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-1555

2. Registrant Information.

Registrant Reference Number: Prosar 1-18140149

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.

16-APR-09

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

16-APR-09

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)

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

Product Name: Ratak (non-specific Brodaficoum based rodenticide)

• Active Ingredient(s)
  • BRODIFACOUM

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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.

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

• Cardiovascular System
  • Symptom - Chest pain
  • Specify - "Feels like he is having a heart attack"

• Gastrointestinal System
  • Symptom - Difficulty swallowing

• Nervous and Muscular Systems
  • Symptom - Anxiety
  • Specify - "Feels like he is having a panic attack"

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?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

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.

Skin

Oral

11. What was the length of exposure?

<=15 min / <=15 min

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.)

1-18140149: A reporter called on 04/16/2009 to report his exposure to an anti-coagulant rodenticide containing the active ingredient Brodifacoum. According to the reporter, he touched a piece of the product at an unknown time prior to the report and put his hand in his mouth. At the time of the report, the reporter stated that he was having trouble swallowing and felt like he was having a heart attack. The reporter was advised that the signs described are not expected with the exposure described. The reporter was advised to hang up and call 911. The reporter denied needing 911 assistance and disconnected. The reporter called again 20 minutes after the initial report and stated that he felt like he was having a heart attack. The reporter was asked if he needed 911 assistance. The reporter stated that he did not need 911 assistance and thought he was having a panic attack. The reporter was advised that he needed to contact 911 for the signs reported. The reporter was also advised that 911 would be called for him if needed. No further information was obtained.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

The signs described are not expected with the exposure described. This product has a bitterant and the obnoxious taste may have caused the response described. There is no indication of the time between the alleged exposure and the effects reported. However, the bitterant effect would be immediate.