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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-3570

2. Registrant Information.

Registrant Reference Number: PROSAR Case#: 1-34027586

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.


  • General
    • Symptom - Malaise
  • Nervous and Muscular Systems
    • Symptom - Headache
    • Symptom - Muscle pain
    • Symptom - Aching
    • Specify - achiness

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?

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.)

1-34027586- The reporter, a farmer, indicates a worker he employs may have been exposed to an insecticidal product containing the active ingredient lambda-cyhalothrin. The reporter indicated the adult male one week prior to the initial report may have gotten a few drops of the product on his skin and may have been exposed to some product vapor. The reporter did not describe if this occurred during application or in what other context the exposure may have occurred. The caller comments no exposure incident was observed and consequently no decontamination or washing had taken place. The caller reports the worker had noted symptoms that were thought to be attributable to a cold or respiratory tract virus before the possible exposure date, but the symptoms worsened after the usage date. The caller indicated the worker had flu-like symptoms for the week after the possible exposure. Symptoms were clarified as malaise, headache and achiness. The worker had been to the doctor and was told by the physician his symptoms were likely due to a virus. The caller was advised severity and duration of the symptoms described were not consistent with the expectations of the product. He was advised doctors assessment was likely correct and any recommendations made by the treating physician should be followed. No additional information is available.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.