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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-2816
2. Registrant Information.
Registrant Reference Number: PROSAR Case #: 1-30529160
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.
17-JUN-125. Location of incident.
Country: CANADA
Prov / State: SASKATCHEWAN
6. Date incident was first observed.
16-JUN-12Product 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. 24984 PMRA Submission No. EPA Registration No.
Product Name: Matador 120EC Emulsifiable Concentrate Insecticide
- Active Ingredient(s)
- LAMBDA-CYHALOTHRIN
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.
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
- Nervous and Muscular Systems
- Symptom - Numbness
4. How long did the symptoms last?
>8 hrs <=24 hrs / > 8 h < = 24 h
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
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.
>8 hrs <=24 hrs / > 8 h < = 24 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.)
1-30529160- A caller indicated an exposure to an insecticide containing the active ingredient lambda-cyhalothrin. The reported stated he had been cleaning equipment the day prior to his initial contact with the registrant and had a dermal exposure to the product on his arm and face. He indicated he had washed those areas after the exposure, but had since experienced numbness of the skin exposed. The reporter was advised transient sensations of this nature may be expected following exposure to the class of insecticide. He was advised of proper decontamination procedures, symptomatic care and the threshold at which he may seek medical assistance. On follow up he indicated his symptoms had spontaneously resolved within twenty four hours. No further information is available.
To be determined by Registrant
14. Severity classification.
Minor
