Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-5189

2. Registrant Information.

Registrant Reference Number: PROSAR case #: 1-41544181

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.

11-AUG-15

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

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

Product Name: Matador 120EC

• 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.

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

• Skin
  • Symptom - Tingling skin
  • Symptom - Red skin

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Unknown

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

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.)

1-41544181 - The reporter indicated that he had been exposed to an insecticide containing the active ingredient Lambda-cyhalothrin. On the day of initial contact with the registrant the reporter was wearing gloves when he touched a bottle of the concentrated product. When he removed the glove he got some on his finger and then he touched his face with the contaminated finger. Right after skin contact he had some tingling. He had been rubbing the area and at the time of the call the skin was red. The reporter was advised that exposure may cause short-term parasthesia and vitamin E oil was recommended. The reporter could not be reached on routine follow-up attempts. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.