Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2014-4226
2. Registrant Information.
Registrant Reference Number: PROSAR case number: 1-37875308
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.
Domestic Animal
4. Date registrant was first informed of the incident.
22-JUL-14
5. Location of incident.
Country: UNITED STATES
Prov / State: PENNSYLVANIA
6. Date incident was first observed.
14-JUL-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)
PMRA Registration No.
PMRA Submission No.
EPA Registration No. 100-1232
Product Name: Demand EZ Insecticide
- Active Ingredient(s)
- LAMBDA-CYHALOTHRIN
- Guarantee/concentration 2.43 %
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: Res. - Out Home / Rés - à l'ext.maison
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?
No
Subform III: Domestic Animal Incident Report
1. Source of Report
Other
2. Type of animal affected
Fish / Poisson
3. Breed
Koi
4. Number of animals affected
6
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>3 days <=1 wk / >3 jours <=1 sem
11. List all symptoms
System
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
No
14. a) Was the animal hospitalized?
No
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
16. How was the animal exposed?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1-37875308 - The reporter, a pest control operator, indicated that an unknown number of koi were exposed to an insecticide containing the active ingredient Lambda-cyhalothrin. The reporter stated that his technician applied the diluted product outside a customers home 13 days prior to initial contact with the registrant. During application the technician accidentally sprayed within a few feet of a self-contained, 3-foot deep, man-made fish pond that contained an unknown number of koi. Five days later, the fish owner found a number of dead koi in his pond. The reporter did not know the exact number of koi that were found but he indicated that it was more than 5. The reporter stated that he did take water samples which have been submitted for analysis. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here