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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-2220

2. Registrant Information.

Registrant Reference Number: PROSAR Case 1-30068245

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.

Human

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

6. Date incident was first observed.

Unknown

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. 27577      PMRA Submission No.       EPA Registration No.

Product Name: Apron Maxx RTA Fungicide Seed Treatment

• Active Ingredient(s)
  • FLUDIOXONIL
  • METALAXYL-M (MEFENOXAM)

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.

Other

2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Swollen eye
  • Symptom - Irritated eye
  • Symptom - Red eye

• Skin
  • Symptom - Other
  • Specify - DX: Shingles on forehead

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

Unknown

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

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.

Eye

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>24 hrs <=3 days / >24 h <=3 jours

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.)

1-30068245- The reporter indicated a family member had been exposed to fungicidal seed treatment containing the active ingredients Metalaxyl-M and Fludioxonil. The reporter indicated his father may have gotten the product in his eye the week prior to his initial contact with the registrant. The caller did not clarify in what capacity the caller was working with the product. No discreet exposure was described. The caller made the inference that his father was exposed because he had noted his right eye had developed redness, irritation and selling within three days of the possible exposure. His father had been to an optometrist and prescribed an unnamed eye drop that had not provided relief. The caller was advised his family member should return to the doctor due to the severity and ongoing nature of the symptoms seen. On follow up six days later the reporter stated his father was seen by a physician and was diagnosed with shingles and his symptoms had resolved. The symptoms and diagnosis are inconsistent with the profile of the active ingredient and finished product. No further information is available.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.