Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-0843

2. Registrant Information.

Registrant Reference Number: PROSAR CASE# 1-23046331

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.

09-JUN-10

5. Location of incident.

Country: UNITED STATES

Prov / State: NEW JERSEY

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.       PMRA Submission No.       EPA Registration No. 100-1066

Product Name: Demand CS

• Active Ingredient(s)
  • LAMBDA-CYHALOTHRIN
    • Guarantee/concentration 9.7 %

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 100-1004

Product Name: Demon EC

• Active Ingredient(s)
  • CYPERMETHRIN
    • Guarantee/concentration 25.3 %

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. Unknown

Product Name: Talon G (non-specific)

• Active Ingredient(s)
  • BRODIFACOUM
    • Guarantee/concentration .005 %

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7. b) Type of formulation.

Liquid

Bait

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.

Other

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Death

4. How long did the symptoms last?

Persisted until death

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

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)

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.

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.)

1-23046331- The registrant was notified through litigation of possible exposure to three pesticide products containing the active ingredients, lambda-cyhalothrin, cypermethrin, and brodifacoum. Initially when the registrant was informed (06/09/10) it was unclear which products were involved and reporting was not possible. Updated documentation 12/20/10 facilitated reporting. The proposed exposure had taken place in occupational setting (unknown occupation). A male (unknown demographics) was reported to have been exposed on a daily basis to the listed products via inhalation, dermal contact, as well as ¿¿¿other means? (not clarified). No discreet exposure incident was described. The exposure was reported to have taken place between 10/--/96 and 12/--/07. The exposed individual is reported to be deceased (unknown time of death, unknown cause). No further information is available at this time.

To be determined by Registrant

14. Severity classification.

Death

15. Provide supplemental information here.