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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-1839

2. Registrant Information.

Registrant Reference Number: AMV

Registrant Name (Full Legal Name no abbreviations): AMVAC Chemical Corporation

Address: 4695 MacArthur Court, Suite 1250

City: Newport Beach

Prov / State: CA

Country: United States

Postal Code: 92660

3. Select the appropriate subform(s) for the incident.


4. Date registrant was first informed of the incident.


5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.


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. 26509      PMRA Submission No.       EPA Registration No.

Product Name: Prelude 240

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


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

Site: Pub. Area - Indoor/Zone publique - int

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?


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.


  • General
    • Symptom - Malaise
  • Respiratory System
    • Symptom - Wheezing
    • Symptom - Coughing
  • Cardiovascular System
    • Symptom - Chest pain
  • Skin
    • Symptom - Flushed
  • Cardiovascular System
    • Symptom - Irregular heart rate
  • General
    • Symptom - Flu-like symptoms

4. How long did the symptoms last?

Unknown / Inconnu

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


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


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

Contact with treated area

Amount of time between application and contact 3

Hour(s) / Heure(s)

What was the activity? described as "working in area" not further clarified

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


10. Route(s) of exposure.


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.)

The reporter indicated he may have been exposed to a pesticide containing the active ingredient permethrin. The reporter indicated the product was applied by a commercial pest control operator to his work place three weeks prior to his initial contact with Syngenta. The application rate was not clarified by the caller. He reports he re-entered the application area three hours following application. He indicates the day of re-entry he experienced ¿¿¿flu-like symptoms¿¿¿ as well as wheezing and he ¿¿¿felt hot¿¿¿. He did not clarify when those symptoms developed in relationship to his re-entry, how long he was in the application area, and did not describe a discreet exposure incident. He indicated he reported to his local emergency room (exposure day 19-Jan-2011) in response to the symptoms experienced. He indicates he was diagnosed with an ¿¿¿irregular heartbeat¿¿¿ was given fluids (route not offered) and advised to follow up with a cardiologist. The reporter indicated the symptoms resolved spontaneously within 24-48 hours. He indicates he had a follow up with a cardiologist and an ECG was performed. The doctor found no abnormalities (roughly 1 week prior to second visit to ER). The reporter indicated he had experienced wheezing coughing again on 6-Mar-2011 and then chest pain 7-Mar-2011 and went to the ER that day. He called Syngenta from the emergency room (7-Feb-2011) where they had done an ECG and found no abnormalities. The reporter asks if his symptoms might be related to the described exposure. The reporter was advised both the symptoms and time line were inconsistent with simple re-entry to an application site where the product was used. Further, the spectrum of symptoms is inconsistent with the toxicity profile of the active ingredient. No further information is available. This call was taken by Prosar, on behalf of Syngenta. The Syngenta contact information was on the product. This product was originally Syngenta's product, and was transferred to AMVAC in 2007. AMVAC did not speak directly to the subject.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.