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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-4873

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-31662872

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: QUEBEC

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. 27428      PMRA Submission No.       EPA Registration No.

Product Name: Demand CS

• 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: Res. - In Home / Rés. - à l'int. maison

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: Female

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

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Paresthesia

• General
  • Symptom - Sweating
  • Specify - night sweats

• Skin
  • Symptom - Pain

• General
  • Symptom - Lethargy

• Skin
  • Symptom - Skin sensitivity
  • Symptom - Burning skin
  • Specify - skin feels like it is on fire
  • Symptom - Tingling skin

• Nervous and Muscular Systems
  • Symptom - Numbness
  • Specify - skin numbness

• General
  • Symptom - Fatigue

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

Non-occupational

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

Contact with treated area

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.

Unknown

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.)

1-31662872 - The reporter indicated that she was exposed to an insecticidal product containing the active ingredient Lambda-cyhalothrin and to a non-registrant product with unknown active ingredients. The reporter, an adult female indicated that the product was sprayed in her house by a pest control operator three times in the last three months and each application was approximately 3-4 weeks apart. The reporter indicated that since the product was applied she has been experiencing fatigue, and a skin reaction; her skin feels like it is on fire and she has intolerance to hot and cold, all of her skin is also affected by a tingling and numb sensation which is worse on her hands, feet and face. She is also experiencing night sweats. The reporter indicated that she has been to the doctor who ran blood work which was normal. The reporter was advised that contact with the wet product may cause transient paraesthesia but symptoms typically resolve within 24 hours. Prolonged symptoms are not consistent with product exposure and continued medical evaluation was recommended. No further information is available.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.