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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-2800

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-30474741

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.

12-JUN-12

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

23-MAY-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)

PMRA Registration No. 28821      PMRA Submission No.       EPA Registration No.

Product Name: Cruiser Maxx Beans Seed Treatment

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

7. b) Type of formulation.

Application Information

8. Product was applied?

No

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.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: >6 <=12 yrs / > 6 < = 12 ans

3. List all symptoms, using the selections below.

System

  • Skin
    • Symptom - Blister

4. How long did the symptoms last?

>1 wk <=1 mo / > 1 sem < = 1 mois

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

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Contact with treated area

What was the activity? Child handling treated beans

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.

Unknown / Inconnu

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.)

1-30474741- The reporter, an employee of the registrant, indicated a child was exposed to seed (beans) treated with the fungicides/insecticide metalaxyl-m, Fludioxonil, and thiamethoxam. The caller reported the incident to the medical service for the registrant. Subsequently the parent of the affected child was contacted. The mother of the (age) (numbe) pound male child reported her son had picked up three treated beans twenty days prior to the initial report. She indicates the child had experienced blistering on the surface of his hands shortly after handling the beans. She did not clarify the duration between exposure and onset or describe any decontamination following exposure. The child was not seen by a doctor but fully resolved within one and one half weeks with symptomatic care that was not described by the parent. The parent also added the child had been camping just before the development of the symptoms. She implied he had engaged in activities which may have led to the observed symptoms. Blistering would not be expected following dermal exposure to beans treated with these active ingredients. No further information is available.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.