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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-3569

2. Registrant Information.

Registrant Reference Number: PROSAR Case#: 1-34039070

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.


4. Date registrant was first informed of the incident.


5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.


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. 24984      PMRA Submission No.       EPA Registration No.

Product Name: Matador 120EC

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


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?


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.


  • Nervous and Muscular Systems
    • Symptom - Headache
  • General
    • Symptom - Malaise
  • Respiratory System
    • Symptom - Respiratory irritation
  • Nervous and Muscular Systems
    • Symptom - Muscle pain
  • Blood
    • Symptom - Other
    • Specify - 'elevated pH and carbon dioxide'

4. How long did the symptoms last?

Unknown / Inconnu

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


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


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)


10. Route(s) of exposure.


11. What was the length of exposure?

>15 min <=2 hrs / >15 min <=2 h

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.)

1-34039070- The reporter indicated he may have been exposed to a product containing the active ingredient lambda cyhalothrin. The reporter stated he was working with the product the day prior to his initial report. He had removed the back pack sprayed containing the product and the sprayer was stuck in the on position spraying his arm. The caller stated the product was significantly diluted prior to exposure but was unable to give the dilution ration used. The caller also commented he had added to the sprayer two non-registrant products by the names Liberty and Centurion. The caller had rinsed his skin and noted no dermal symptoms associated with the exposure. The next day he noted headache, malaise, respiratory irritation, and body aches. The caller was advised dermal contact with the registrants product would not be anticipated to elicit these symptoms. He was encouraged to see his doctor and to contact the registrants of the Liberty and Centurion product to discuss the expectation of their products. The reporter was contacted the next day. He stated he did go to the emergency room where his blood was drawn. He commented he was found to have an elevated pH and carbon dioxide. He received no treatment, but had resolved spontaneously. No further information is available.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.