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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-1084

2. Registrant Information.

Registrant Reference Number: ProPharma Group case #: 1-51466834

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: ONTARIO

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. Unknown

Product Name: DEMAND CS INSECTICIDE

• 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

• Skin
  • Symptom - Burning 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

Non-occupational

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

Contact with treated area

What was the activity? re-entry into the home after 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.

Unknown

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.)

1-51466834 - The reporter indicates an exposure to a pesticide containing the active ingredient lambda-cyhalothrin. Approximately 32 hours before the time of initial contact with the company, the reporter indicated her home had been sprayed with the product by a pest control officer. The reporter indicated she did not re-enter her home for approximately 6 hours after the product had been sprayed, but an unknown amount of time later, she indicated her face felt like it was burning. The reporter was advised to thoroughly wash off her face and if the symptoms dont resolve in 24 hours, medical care should be sought. On follow-up call three days later, the reporter indicated the symptoms still persisted. No additional information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.