Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-0451

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-24894637

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.

07-DEC-10

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

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)

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PMRA Registration No. 24485      PMRA Submission No.       EPA Registration No.

Product Name: Avid 1.9% EC Miticide Insecticide

• Active Ingredient(s)
  • ABAMECTIN

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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: Unknown / Inconnu

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 used the product one time only 2 weeks prior to the call. It had been diluted with water and sprayed from a spray bottle. The reporter stated he did not believe he got any product on his skin during application.

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

• Skin
  • Symptom - Rash

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

Unknown

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

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.)

1-24894637: The reporter called on 12/7/10, indicating he had used a miticide product containing the active ingredient Abamectin two weeks prior to the call. The product had been used one time only - diluted with water and sprayed from a spray bottle. The reporter stated he did not believe he got any product on his skin during application; however, he had recently developed a rash. The rash had spread up his right forearm to his shoulder, as well as on a portion of his face. He also stated that a small rash was present on his penis. The reporter speculated that he got the product on his hands and transferred it to other parts of this body. During the call, the reporter was instructed about the safety profile of the product. It was discussed that the symptoms were likely unrelated to the product, given: a) no clear evidence of exposure and b) the time lag between product application and the onset of the rash. A recommendation was made to follow up with a dermatologist to rule out other causes for the rash.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

No direct evidence of exposure. Time lag between use of produce and onset of symptoms would indicate no involvement with the product. Symptoms are not consistent with exposure to product.