Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-4487

2. Registrant Information.

Registrant Reference Number: PROSAR Case #1-27153558

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.

16-AUG-11

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

08-AUG-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.       PMRA Submission No.       EPA Registration No. Unknown

Product Name: Prelude (nonspecific)

• Active Ingredient(s)
  • PERMETHRIN

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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: Pub. Area - Indoor/Zone publique - int

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 - Nausea

• Nervous and Muscular Systems
  • Symptom - Dizziness

• Cardiovascular System
  • Symptom - Hypertension

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Contact with treated area

Amount of time between application and contact 2

Hour(s) / Heure(s)

What was the activity? re-entry of a hotel room (application area)

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?

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.)

1-27153558- The reporter indicated he was exposed to an insecticide containing the active ingredient permethrin. The reporter was unable to provide label information (precise name or registration number) for the product he was calling about. He indicates a hotel where he was staying was sprayed with the product eight days preceding his initial contact with the registrant. He reports he re-entered that room two hours following application. He was unable to describe a discreet exposure incident and did not indicate an aroma was encountered. He reported within one hour of re-entry he noted the symptoms of nausea and dizziness. Two days following initially noting the described symptoms he had gone to a doctor and was diagnosed with high blood pressure. He was given medication to address his hypertension but his symptoms had persisted until the time of the initial contact with the registrant. He was concerned the symptoms may be related to the product. The caller was advised both the symptoms and the persistent nature of those symptoms were inconsistent with the toxicity profile of the active ingredient. It was recommended he continue to work with his physician to determine the cause of his symptoms and the appropriate therapy. The caller was not reached for follow up. No further information is available.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.