Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-2587

2. Registrant Information.

Registrant Reference Number: PROSAR 1-22508316

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.

05-MAY-10

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

30-APR-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.       PMRA Submission No.       EPA Registration No. Unknown

Product Name: Cruiser Maxx 250 (Cruiser 5FS + Maxim XL + Apron XL+ Dynasty 100FS)

• Active Ingredient(s)
  • AZOXYSTROBIN
  • FLUDIOXONIL
  • METALAXYL-M (MEFENOXAM)
  • THIAMETHOXAM

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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: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: Treated seed, unknown type

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

The reporter indicated he had applied fungicide coated seeds (seed type unknown, coating contained the active ingredients Thiamethoxam, Metalaxyl-M, Fludioxonil and Azoxystrobin) on 4/28/10. The reporter developed symptoms 2 days later.

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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Dry skin
  • Symptom - Lesion
  • Specify - Welt on forehead
  • Symptom - Pruritus

4. How long did the symptoms last?

>3 days <=1 wk / >3 jours <=1 sem

5. Was medical treatment provided? Provide details in question 13.

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

8. How did exposure occur? (Select all that apply)

Application

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

Respiratory

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.)

1-22458158: The reporter called the registrant on 5/5/10 to report his exposure to fungicide coated seeds (type unknown); the coating contained the active ingredients Thiamethoxam, Metalaxyl-M, Fludioxonil and Azoxystrobin. According to the reporter, he had applied the seed on 4/28/10. On 4/30/10, the reporter developed a welt on his forehead. He speculated that he may have gotten some of the seed coating on his forehead, but also thought the welt might be related to a tight cap he was wearing. By the time of the call, his symptoms had mostly resolved though he had some dry and pruritic skin in that area. The safety profile of the product was discussed, and the reporter was encouraged to seek medical care to determine the cause of his symptoms.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

The symptoms as described are not consistent with exposure to any of the active ingredients involved