Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-3643

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-26961962

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.

27-JUL-11

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

6. Date incident was first observed.

26-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?

Yes

9. Application Rate.

Unknown

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?

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

• Gastrointestinal System
  • Symptom - Stomach cramps

• General
  • Symptom - Lightheadedness

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.

Unknown

11. What was the length of exposure?

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

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.)

1-26961962- The reporter called to indicate he had been exposed to an insecticide containing the active ingredient lambda cyhalothrin. The reporter indicated he had mixed and sprayed the diluted product over the course of a twelve hour time frame five days prior to his initial contact with the registrant. He indicated he cleaned the sprayer three days later. The caller did not describe the capacity in which he had used the product nor did he describe the use of any personal protective equipment. The caller stated he did not believe he had gotten any of the product on himself. He did not describe a discreet exposure incident. The reporter indicated four days following application he developed stomach cramps and the day of his initial contact (five days after application) he had developed lightheadedness. The reporter was advised to consider other potential causes for his current illness and seek medical advice if the symptoms worsened or persisted. The symptoms and time line seen are inconsistent with the toxicity profile of the product and active ingredient. The caller was not reached on follow up attempt. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.