Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-3658

2. Registrant Information.

Registrant Reference Number: PROSAR case #: 1-41455898

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.

02-AUG-15

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

26-JUL-15

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. 27428      PMRA Submission No.       EPA Registration No.

Product Name: Demand CS

• Active Ingredient(s)
  • LAMBDA-CYHALOTHRIN

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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.

Other

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Itchy skin

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.

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Unknown

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.

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.)

1-41455898 - The reporter indicated that his brother was exposed to an insecticide containing the active ingredient Lambda-cyhalothrin. The reporters brother applied the product (application site was not indicated) one week prior to initial contact with the registrant and sometime after use he developed itchy skin around his eyes, eyebrows and cheeks. The reporter was advised that exposure may cause short-term paresthesia and vitamin E oil was recommended. On follow-up call, two days later, the reporter indicated that his brother's symptoms lasted a total of four days and at the time of the follow-up he was doing fine. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.