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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2228

2. Registrant Information.

Registrant Reference Number: PROSAR Case : 1-26082055

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.


4. Date registrant was first informed of the incident.


5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

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. 29192      PMRA Submission No.       EPA Registration No.

Product Name: Cruiser Maxx Cereals

  • Active Ingredient(s)

PMRA Registration No. 27577      PMRA Submission No.       EPA Registration No.

Product Name: Apron Maxx RTA Fungicide Seed Treatment

  • 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).

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.


  • Nervous and Muscular Systems
    • Symptom - Headache
    • Symptom - Aching
  • General
    • Symptom - Chills
  • Nervous and Muscular Systems
    • Symptom - Muscle tremors
  • General
    • Symptom - Lethargy
  • Eye
    • Symptom - Other
    • Specify - glassy eyed
  • Respiratory System
    • Symptom - Coughing up blood
    • Symptom - Other
    • Specify - coughing up mucus/tonsils inflamed

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)

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

Chemical resistant gloves

10. Route(s) of exposure.


11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>24 hrs <=3 days / >24 h <=3 jours

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.)

1-26082055- The reporter indicated her son may have been exposed to two pesticides. The first contained the active ingredients difenoconazole, mefenoxam, and thiamethoxam. The second contained fludioxonil and mefenoxam. The caller indicated her (age) old son worked with the former product three or four days prior to her initial contact with the registrant. He was reported to have worked with the latter two days prior to her contact with the registrant. The caller did not clarify in what capacity her son worked with the two products. The caller did not describe a discreet exposure incident. She indicated when he got out of the truck he felt achy, had a headache and back ache. She reports he also described chills and was shaking. She indicated his eyes were glassy and he was listless. She did not clarify when he experienced these symptoms with respect to working with the products or with respect to her initial call to the registrant. She reported her son had gloves (non specific) and boots on but did not have a mask. She reports he may have been exposed to the product (unknown which) for 1-2 hours. The caller indicates she believed the symptoms were related to exposure due to the fact that he had a similar experience the year prior when applying the same products. The caller added at the end of her call her son was currently coughing up bloody mucus and his tonsils were inflamed. The caller was advised the symptoms described were inconsistent with the toxicity profile of the active ingredients described, the time line described and the avenue described. She was advised to heave her son seek medical care and to consider other causes for his symptoms. On follow up the caller indicated her son was seen by a doctor and no diagnosis was reached. He was placed on an oral antibiotic for his symptoms, no diagnostics were indicated. The caller was advised despite the apparent unrelatedness of the symptoms to the products used her son should use appropriate personal protective equipment when working with this and all pesticides. She was supplied with a MSDS to describe appropriate PPE used in an occupational setting when working with the described products. No further information is available.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.