Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-1233

2. Registrant Information.

Registrant Reference Number: PROSAR 1-21784034

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.

27-FEB-10

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

25-FEB-10

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. 26509      PMRA Submission No.       EPA Registration No.

Product Name: Prelude 240

• Active Ingredient(s)
  • PERMETHRIN

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7. b) Type of formulation.

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 was applied inside the residence on 02/25/2010.

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: Male

Age: <=1 yr / < = 1 an

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Lethargy

• Gastrointestinal System
  • Symptom - Anorexia

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)

Contact with treated area

What was the activity? Playing with toys that may have been sprayed with product

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.)

1-21784034: A reporter called on 02/27/2010 to report the possible exposure of her (age) son to a pesticide containing the active ingredient Permethrin. According to the reporter, the product had been applied inside the home on 02/25/2010. Starting on the day of the report, the baby was lethargic and not eating. The reporter was concerned that he had been playing with toys that may have been sprayed with the product. The reporter was advised that the product has a wide margin of safety. Once the product is dry, exposure is not expected. Dermal or ingestion exposure to wet product may be irritating to the skin or gastrointestinal tract, but significant signs are not anticipated. A recommendation was made to have the child evaluated by a health care provider to determine the cause for the signs. No further information was obtained.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

There is no evidence the toys were actually spayed. Symptoms are not consistent with exposure to Permethrin.