Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-4011

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-23544654

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.

Domestic Animal

4. Date registrant was first informed of the incident.

22-JUL-10

5. Location of incident.

Country: UNITED STATES

Prov / State: OKLAHOMA

6. Date incident was first observed.

22-JUL-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. 100-990

Product Name: Demon WP Insecticide

• Active Ingredient(s)
  • CYPERMETHRIN
    • Guarantee/concentration 40 %

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7. b) Type of formulation.

Wettable or soluble powder

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Res. - Out Home / Rés - à l'ext.maison

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 III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Maltese

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

1

7. Weight (provide a range if necessary )

5

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• General
  • Symptom - Death

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

No

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

16. How was the animal exposed?

Other / Autre

specify unknown

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

1-23544654- The reporter, a pet owner, calls to indicate possible exposure of her animal to an insecticide containing the active ingredient cypermethrin. The caller describes spraying diluted product outside of her home earlier in the day. She reports a cupcake (human food item) was seen in the application area covered with insects, so she sprayed it with the diluted product. The food item was not removed and was later missing. The caller indicates she has a 10-12 week 7-8 pound mixed breed dog and is concerned the animal may have ingested the food item. The animal was asymptomatic at the time of the call and no ingestion was observed. The caller was advised small ingestions of diluted product would be expected to elicit no more that potential gastrointestinal irritation. The caller was advised of supportive measures if signs were observed and the threshold at which she might seek veterinary care. On routine call back the reporter indicated her animal remained asymptomatic. She indicates her neighbors five pound one year Maltese dog (Subform III, #1) may have ingested the food item as it was found dead the morning of the call back. The reporter indicates the animal is housed outside and was found in the morning with no signs leading to its demise. No ingestion or exposure was observed. No veterinary examination or necropsy was reported. No further information is available. Sudden death is inconsistent with ingestion exposure to small amounts of diluted active ingredient.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here

There was no direct evidence of exposure. The symptoms, as described, are not consistent with exposure to cypermethrin. Death of the animal was attributed to hepatic neoplasia and not to exposure to brodifacoum anticoagulant.