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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-1213

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-29002567

Registrant Name (Full Legal Name no abbreviations): Syngenta 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.


Prov / State: CALIFORNIA

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.       PMRA Submission No.       EPA Registration No. 100-1066

Product Name: Demand CS

  • Active Ingredient(s)
      • Guarantee/concentration 9.7 %

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: Res. - In Home / Rés. - à l'int. maison

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.


  • Respiratory System
    • Symptom - Coughing
    • Symptom - Pneumonia

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)

Contact with treated area

Amount of time between application and contact .25

Hour(s) / Heure(s)

What was the activity? Walking through treatment area/residential facility common area

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?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

1-29002567-The reporter described a potential exposure to an insecticidal product containing the active ingredient lambda-cyhalothrin. The reporter indicated he is an employee of a workmans compensation group that had been contracted to investigate a case. He reported the patient is a (age) year old male with lots of health issues. The caller was able to provide only that the patient had COPD and was a smoker. He reported on 12/21/12 the patient entered a residential common area where the product had been applied by a commercial pest control operator 15 minutes prior. The reporter indicated carpet cleaning had also been performed in the area within several days of the incident. The patient developed coughing within 5-15 minutes and promptly left the application area. No symptoms were reported for the next two days. On 12/29/12 the patient was hospitalized in (state). The reason for the hospitalization was unknown as the patients medical records were unavailable. The patient was released from the hospital 12/29/12. The patient then returned home and on 01/12/12 the patient was again hospitalized where he remained until the point of the initial report one month later. The patient was reported to be in a medically-induced coma to facilitate the respirator and assisted feeding. The reporter stated the iatrogenic coma was the patient's choice, due to anxieties about having tubes in him. The diagnosis was "double pneumonia". The reporter was advised the time line and severity of symptoms are inconsistent with the toxicity profile of the active ingredient of the finished product. Aromas of pesticides can sometimes irritate the airway, most notable in individuals with pre-existing disease. But, these individuals can equally be sensitive to any aroma such as perfumes and cleaning supplies. He was advised the patients symptoms were not likely related to the described contact with the application area. On follow up the reporter indicated the patient was unchanged one day later. He reported the diagnosis of double pneumonia was provided by the patiens wife not by a health care professional or the medical record. One further follow up attempt was made, at which point the reporter indicated he had been taken off the case and would have no further information. No alternative contact was provided. No further information is available.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.