Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-2820

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-30644010

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.

26-JUN-12

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

25-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)

---

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?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Unknown / Inconnu

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: >12 <=19 yrs / >12 <=19 ans

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Erythema
  • Symptom - Irritated skin
  • Symptom - Tingling skin

• Eye
  • Symptom - Irritated eye

4. How long did the symptoms last?

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

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

Occupational

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

Eye

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.)

1-30644010- The reporter, an employee of the registrant, indicated a customer was exposed to an insecticide containing the active ingredient lambda-cyhalothrin. The reporter states the farmer/grower was exposed to the product during application the day prior to her report. She indicated he was sprayed in the face and eyes. His skin was described as red, burning, and tingling. His eyes were irritated. The reporter was advised transient burning tingling sensations to the may be encountered following dermal exposure to the class of insecticide and that ocular irritation may be encountered following exposure by that route. The reporter was advised of proper decontamination technique, symptomatic care and the threshold at which to see a doctor. On follow up the reporter stated the patients symptoms had persisted for no more than forty eight hours. He had not seen a doctor. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.