Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-1358

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-36739782

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.

13-APR-14

5. Location of incident.

Country: UNITED STATES

Prov / State: MISSOURI

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.

Active(s)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 100-1247

Product Name: Cruiser Maxx Beans Insecticide

• Active Ingredient(s)
  • FLUDIOXONIL
    • Guarantee/concentration 1.12 %
  • METALAXYL-M (MEFENOXAM)
    • Guarantee/concentration 1.7 %
  • THIAMETHOXAM
    • Guarantee/concentration 22.61 %

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7. b) Type of formulation.

Dust

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Other / Autre

Préciser le type: On Bean Seeds

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

• Renal System
  • Symptom - Renal failure

• General
  • Symptom - Edema

• Respiratory System
  • Symptom - Pulmonary edema

• Gastrointestinal System
  • Symptom - Other
  • Specify - strep throat

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

Unknown

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

Respiratory

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.)

1-36739782 - The reporter, the father of the patient, indicated that his son was exposed to a fungicide and insecticide bean seed treatment with the active ingredients thiamethoxam, fludioxonil and metalaxyl-m. The reporter indicated that his (age) son works at a bean spraying plant and applies the concentrated product to bean seeds for 10 hours at a time in a small room. During application callers son only wears a mask about 50% of the time. Per the caller all the workers take their masks off during their shift because it gets hard to breath in the room with all the dust in the air. Caller states that his son contracted strep throat and then per the caller the doctors thought that the strep throat lead to system failure which resulted in kidney failure with edema in his legs, and pulmonary edema. At the time of the call the patient had been in the hospital for a period of five days. Per the caller the patient had been treated with multiple antibiotics which have improved his symptoms but each time the antibiotics are stopped the patient goes back into kidney failure again. The reporter was advised that the described symptoms are not consistent with the described exposure to the product. No further information is available.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.