Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-3571

2. Registrant Information.

Registrant Reference Number: PROSAR Case#: 1-34024031

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.

17-JUN-13

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

6. Date incident was first observed.

11-JUN-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. 30436      PMRA Submission No.       EPA Registration No.

Product Name: Cruiser Maxx Vibrance Cereals

• Active Ingredient(s)
  • DIFENOCONAZOLE
  • METALAXYL-M (MEFENOXAM)
  • SEDAXANE
  • THIAMETHOXAM

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

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

• Eye
  • Symptom - Irritated eye

• Skin
  • Symptom - Edema

• Eye
  • Symptom - Pain

• Skin
  • Symptom - Rash

• Eye
  • Symptom - Other
  • Specify - fluid buildup or a pocket under his eyes
  • Symptom - Other
  • Specify - water retention and a rash under the eyes of the patient

4. How long did the symptoms last?

>3 days <=1 wk / >3 jours <=1 sem

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

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

11. What was the length of exposure?

Unknown / Inconnu

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.)

1-34024031- The reporter indicated her spouse was exposed to a treated seed. The product was indicated as Cruiser Maxx Vibrance treated barley. The seed treatment is comprised of the active ingredients thiamethoxam, difenoconazole, metalaxyl-M (and S-isomer), and sedaxane. The reporter stated her husband had been working with the seed 06/11/13 through 06/13/13. She did not clarify in what capacity he was working with the product or for what duration on those days he had been working with the product. The caller reports her spouse was wearing a mask and leather gloves. No other personal protective equipment was described. The night of 06/11/13 he developed fluid buildup or a pocket under his eyes and his eyes were irritated. The caller stated he had been using a topical over the counter diphenhydramine product on the area and oral diphenhydramine but he had not received relief. She indicated her husband has allergies. The caller was advised of the potential irritant effect of the grain dust but the symptoms described would not be anticipated to be related to the seed treatment or consistent with any of the active ingredients. The same day of the initial report a nurse practitioner called to report he had seen the patient. The caller described water retention and a rash under the eyes of the patient. The caller commented the area affected did seem to correspond to the area on the callers face not covered by his mask or respirator. The caller did not describe treatment proposed but the caller did comment the patients symptoms may also be related to the barley seed dust. The patients spouse was contacted again three days after the initial report. She indicated her husband had resolved. His symptoms had persisted for five days. No further information is available.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.