Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-3044

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-26730746

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.

05-JUL-11

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

05-JUL-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. 24984      PMRA Submission No.       EPA Registration No.

Product Name: Matador 120EC Emulsifiable Concentrate 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: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Numbness

• Skin
  • Symptom - Pruritus

• General
  • Symptom - Hyperthermia

4. How long did the symptoms last?

>8 hrs <=24 hrs / > 8 h < = 24 h

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

No

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)

Pesticide Spill

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.

>30 min <=2 hrs / >30 min <=2 h

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.)

1-26730746-The reporter indicated a co-worker had been exposed to an insecticide containing the active ingredient lambda-cyhalothrin. The reporter had indicated his adult male co-worker had spilled the concentrated product on his belly area within the past hour and one half. The exposed individual had gone home immediately following the exposure to wash the spilled product off his skin, however, it a had taken thirty minutes for him to get home to effectively decontaminate and remove contaminated clothing. The reporter indicated the co-worker was at the time of the call itching his skin, feeling hot, and his face was flushed. The caller disconnected the call before effective treatment advice could be offered. When he was contacted again by phone he indicated he was taking his co worker to the hospital and again disconnected. On routine follow up two days later the reporter indicated his co-worker had recovered within twelve hours. He did not see a physician despite the previous communication. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.