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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2229

2. Registrant Information.

Registrant Reference Number: PROSAR Case 1-26097377

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


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)

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: Unknown / Inconnu

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.


2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.


  • Gastrointestinal System
    • Symptom - Anorexia
    • Symptom - Nausea
    • Symptom - Vomiting
    • Symptom - Diarrhea
    • Symptom - Loss of appetite

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)


10. Route(s) of exposure.


11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>3 days <=1 wk / >3 jours <=1 sem

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.)

1-26097377- The reporter indicates her spouse was exposed to a pesticide containing the active ingredients difenoconazole, mefenoxam, and thiamethoxam. The reporter indicated her husband had been working with the product for the six days prior to her initial contact with the registrant. She indicates he was operating a drill used to do seeding (unspecified) and she is concerned he may have inhaled vapors associated with the product. She did not describe a discreet exposure incident. She indicates he had developed the symptoms of nausea, vomiting, diarrhea and loss of appetite the morning of her initial contact with the product. She states the flu is going around the area as well and is unsure what might be causing his symptoms. The caller reported the possible exposure would have been brief and in a well ventilated area if it did take place. The caller was advised the symptoms described would not be expected as described. She was advised to consider other potential causes for the symptoms described. She was encouraged to seek medical care to assist in diagnosis and treatment should her spouses symptoms persist or worsen. The caller was unreachable for follow up. No further information is available.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.