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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-6824

2. Registrant Information.

Registrant Reference Number: PROSAR case #: 1-42462725

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.

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

Unknown

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.

PMRA Registration No. 27428      PMRA Submission No.       EPA Registration No.

Product Name: Demand CS

• Active Ingredient(s)
  • LAMBDA-CYHALOTHRIN

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: Res. - In Home / Rés. - à l'int. 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?

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: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Other
  • Specify - swollen lymph nodes

• Nervous and Muscular Systems
  • Symptom - Headache

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)

Contact with treated area

What was the activity? Daily living

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.

Respiratory

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.)

1-42462725 - The reporter indicated that she had been exposed to an insecticide containing the active ingredient Lambda-cyhalothrin. A pest control operator applied the product in the reporters apartment, at some unspecified time. The reporter first entered the application site on the day of initial contact and was concerned because the product had been applied to her bed and her couch. At the time of the call the reporter was complaining of swollen glands. On follow-up call, one day later, the reporter indicated that her glands were still swollen and she was still having intermittent headaches. The reporter was advised that per package labeling the product is not meant to be applied on furniture surfaces or mattresses where people will be laying or sitting. The reporter was further advised that swollen lymph nodes are not expected from inhalation of the fumes but headaches can be seen. Ventilation of the home was recommended and if the headaches persist clean-up of the application site was recommended. No additional information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.