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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-0807

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-24657795

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.

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.

PMRA Registration No. 28821      PMRA Submission No.       EPA Registration No.

Product Name: Cruiser Maxx Beans Seed Treatment

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

7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

9. Application Rate.

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

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 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 - Blister
  • 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)

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

None

10. Route(s) of exposure.

Skin

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.)

1-24657795- The reporter, an employee of a grain and feed supply retailer, indicates exposure of customer to a seed treated with the active ingredients Thiamethoxam, Metalaxyl-M, and Fludioxonil. The reporter indicated he was informed by his customer the product was handled at the beginning of the growing season and soon after dermal symptoms had developed. The exposures had not been brought to the attention of the registrant until the end of the growing season. The exposed party was contacted by telephone following notification of the registrant by the vendor. The exposed party stated at some unspecified date at the beginning of the growing season of 2010 he had dumped the product into unspecified machinery and shoveled it around. He suspected he had gotten some dust on his skin. He described no discreet exposure incident. The exposed individual indicated he developed itchy water filled blisters on both arms to the point of which his short sleeved shirt covered his arms and around his left knee. This had occurred at an unspecified time frame following the described work. The exposed party indicated he had not sought medical attention and his symptoms had resolved spontaneously within one week. He had remained asymptomatic. No further information is available

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

Symptoms are not consistent with exposure to the product. Required PPE was not worn while the treated seed was being handled.