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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-2633

2. Registrant Information.

Registrant Reference Number: PROSAR case #: 1-33442238

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: UNITED STATES

Prov / State: NORTH CAROLINA

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.       PMRA Submission No.       EPA Registration No. 100-741

Product Name: Banner Maxx

• Active Ingredient(s)
  • PROPICONAZOLE
    • Guarantee/concentration 14.3 %

PMRA Registration No.       PMRA Submission No.       EPA Registration No. 100-937

Product Name: Primo Maxx

• Active Ingredient(s)
  • TRINEXAPAC-ETHYL

7. b) Type of formulation.

Liquid

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.

Other

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Cancer
  • Specify - leukemia
  • Symptom - Death

4. How long did the symptoms last?

Persisted until death

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

Unknown

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)

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.)

1-33442238 - The reporter, the registrants litigation department, indicated that an adult male may have been exposed to registrant fungicidal and plant growth regulator products containing the active ingredients propiconazole and trinexapac-ethyl. The reporter indicated that the family of the deceased adult male alleges that the patient suffered from leukemia and death due to exposure to these products and numerous other non-registrant products while working as a golf course superintendent. The exposure to the products was not described. The onset of symptoms, duration of symptoms and treatment provided was not described. No further information is available.

To be determined by Registrant

14. Severity classification.

Death

15. Provide supplemental information here.