Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2585

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-26443269

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-11

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

09-JUN-11

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. 27428      PMRA Submission No.       EPA Registration No.

Product Name: Demand CS Insecticide

• Active Ingredient(s)
  • LAMBDA-CYHALOTHRIN

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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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Tingling skin

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

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

Application

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

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.)

1-26443269- The caller indicated exposure to an insecticide containing the active ingredient lambda-cyhalothrin. The caller stated her had been spraying the product in an unknown capacity preceding the call. He reported he had accidentally sprayed himself in the face and had experienced dermal tingling. The caller was frustrated during the call as he did not wish to speak with the registrants medical personnel that were attempting to provide him assistance with the described exposure. The caller indicated he required technical assistance and disconnected the call following the brief initial report. He provided no additional information regarding the exposure. Dermal parasthesias can be consistent with topical exposure to this class of insecticide.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.