Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-2799

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-30448753

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.

10-JUN-12

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

6. Date incident was first observed.

10-JUN-12

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: Other / Autre

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.

Medical Professional

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Erythema
  • Symptom - Irritated skin
  • Symptom - Burning skin

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)

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.

Skin

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>2 hrs <=8 hrs / > 2 h < = 8 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.)

1-30448753-The reporter, a nurse, indicated a patient had presented to her service following an exposure to and insecticide containing the active ingredient lambda-cyhalothrin. The reporter indicated the male patient was sprayed in the face with the product within four and one half hours of the initial report. The caller was unable to describe the circumstances that had led to the exposure or if the product had been diluted. The reporter stated the patient had washed his face with soap and water following contact with a poison control hotline. He had presented to the nurse with the primary complaint of dermal redness and a burning sensation. The reporter was advised self-limiting parasthesias may be encountered following dermal exposure to the pyrethroid class. She was advised of proper decontamination, symptomatic care, and expected duration of the sensation. The reporter was supplied the material safety data sheet on request. The reporter was not available for follow up when the attempt was made. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.