Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-4240

2. Registrant Information.

Registrant Reference Number: PROSAR case number: 1-37993965

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.

01-AUG-14

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

01-AUG-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. 24984      PMRA Submission No.       EPA Registration No.

Product Name: Matador 120EC Emulsifiable Concentrate Insecticide

• Active Ingredient(s)
  • LAMBDA-CYHALOTHRIN

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7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

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?

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: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Red skin

4. How long did the symptoms last?

>2 hrs <=8 hrs / > 2 h < = 8 h

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

Yes

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Other

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

Eye

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.)

1-37993965 - The reporter indicated that his (age) year old father was exposed to an insecticide containing the active ingredient Lambda-cyhalothrin. The reporter stated that sometime within one hour of his initial call the callers father touched the foil lid of the product container and got the concentrated product on his finger. The reporter believes that his father must have then touched his eye because at the time of the initial call the skin around his fathers eyes was red. The reporter was advised that ocular contact may result in transient irritation. Rinsing of the eye was recommended and medical care was advised if symptoms were severe or persistent. On follow-up call, three days later, the reporter indicated that his father went to the emergency room to have the eye flushed and symptoms resolved within 8 hours. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.