Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-3563

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-34210177

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.

04-JUL-13

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

04-JUL-13

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)

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PMRA Registration No. 24984      PMRA Submission No.       EPA Registration No.

Product Name: Matador 120EC Emulsifiable Concentrate Insecticide

• Active Ingredient(s)
  • LAMBDA-CYHALOTHRIN

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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.

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 - Headache

• Skin
  • Symptom - Pruritus

• Gastrointestinal System
  • Symptom - Irritated throat
  • Symptom - Diarrhea

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

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

Oral

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

1-34210177- The reporter indicated he had been exposed to an insecticide containing the active ingredient Lambda-cyhalothrin. The reporter indicated he was applying the product when thirty minutes prior to his initial report he accidentally poked a hole in the jug carrying the product. The caller stated the product was splashed on his shirt, skin and in his mouth. The caller indicated he may have swallowed product when it had splashed in his mouth. The caller indicated he had a headache at the point of the initial call. The caller was advised of proper decontamination technique and of health consequences that can be seen after swallowing and topical exposure to the product. He was informed of the threshold at which to seek medical attention. Follow up was obtained from the reporter one day later. The caller stated he had not seen a doctor. He had experienced topical itch, a sore throat and diarrhea the night of the exposure. He had spontaneously fully resolved at the point of follow up. No additional information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.