Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-2246

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-37238525

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.

28-MAY-14

5. Location of incident.

Country: UNITED STATES

Prov / State: MARYLAND

6. Date incident was first observed.

23-MAY-14

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. Unknown

Product Name: Warrior

• Active Ingredient(s)
  • LAMBDA-CYHALOTHRIN
    • Unknown

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7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: Wheat

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.

Other

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 - Coma
  • Symptom - Collapse

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

Non-occupational

8. How did exposure occur? (Select all that apply)

Drift from the application site

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.

Unknown

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.)

1-37238525 - The reporter, a registrant employee, indicates that a (age) year old male may have been exposed to an insecticide containing the active ingredient Lambda-cyhalothrin. The reporter states that the product was applied to a wheat field adjacent to the patients land 6 days prior to initial contact with the registrant. The reporter further states that the patient was reported to be ill two days prior to product application. The product was applied via ground and air and it was windy on the day of application so there may have been some drift, but the reporter was not aware of how or if the patient was exposed to any drift. The reporter states that the day after application the patient collapsed and has been in a coma and hospitalized since that time. The reporter does not believe symptoms are from the product as the patient was ill 2 days prior to product application. No further information is available.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.