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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-4376

2. Registrant Information.

Registrant Reference Number: Prosar 1-20202712

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.

24-SEP-09

5. Location of incident.

Country: UNITED STATES

Prov / State: GEORGIA

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. 100-1218

Product Name: Demon Max

  • Active Ingredient(s)
    • CYPERMETHRIN
      • Guarantee/concentration 25.3 %

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: Res. - In Home / Rés. - à l'int. maison

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

The product had been applied daily to several times a week for the past 6 months, both inside and outside the home.

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: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

  • Blood
    • Symptom - Anemia

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?

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.

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.)

1-20202712: A reporter called on 09/24/2009 to report her possible exposure to an insecticide containing the active ingredient Cypermethrin. According to the reporter, the reporter's husband had been applying the dilute product daily to several times a week to both the inside and the outside of the home. The reporter indicated that she has never had direct exposure to the product. The reporter indicated that she has been anemic for 6 months. It is unknown whether she has been hospitalized or what treatment she has received. The reporter was advised that the product is not known to cause adverse events related to the bone marrow. Dried product does not pose a threat of toxicity. Dermal exposure to the wet product may result in transient burning or itching sensations. Inhalation of product odor may result in temporary nausea or headache. A recommendation was made to continue working with her physicians to determine the cause of her signs. No further information was obtained.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

The product was used excessively beyond label recommendations.