Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-1597

2. Registrant Information.

Registrant Reference Number: ProPharma Group case #: 1-55708960

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.

27-FEB-19

5. Location of incident.

Country: UNITED STATES

Prov / State: INDIANA

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.

Active(s)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. Unknown

Product Name: TANDEM

• Active Ingredient(s)
  • LAMBDA-CYHALOTHRIN
    • Guarantee/concentration 3.5 %
  • THIAMETHOXAM
    • Guarantee/concentration 11.6 %

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

Product Name: Contrac

• Active Ingredient(s)
  • BROMADIOLONE

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

Product Name: Evergreen

• Active Ingredient(s)
  • PIPERONYL BUTOXIDE
  • PYRETHRINS

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

Product Name: Transport

• Active Ingredient(s)
  • ACETAMIPRID
  • BIFENTHRIN

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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: 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).

1-55708960 - Three non-company products were also applied to the residence at an unknown dilutions and times during the reported time of exposure. These non-company products are Contrac (Bell Laboratories, Inc), Evergreen (McLaughlin Gormley King), and Transport (FMC).

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: Female

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Coughing

• General
  • Symptom - Lethargy

• Respiratory System
  • Symptom - Shortness of breath

• Nervous and Muscular Systems
  • Symptom - Collapse

• General
  • Symptom - Weakness

• Blood
  • Symptom - Hypokalemia

• Eye
  • Symptom - Blindness (temporary)

• Ear
  • Symptom - Hearing loss

• Nervous and Muscular Systems
  • Symptom - Muscle tremors
  • Symptom - Other
  • Specify - Triple reflex brain imbalance
  • Symptom - Other
  • Specify - Severe brain inflammation

• General
  • Symptom - Other
  • Specify - Chronic inflammatory response

• Blood
  • Symptom - Other
  • Specify - Elevated blood diethyl phosphate levels

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

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? residing in her apartment

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.)

1-55708960 - The reporter, a lawyer, indicates an exposure to a pesticide containing the active ingredients thiamethoxam and lambda-cyhalothrin. Starting approximately three-and-one-half years before the day of initial contact with the registrant and continuing for a period of one year, the reporter indicated his client's apartment was intermittently sprayed with the product without the client's knowledge. Approximately two months after initial exposure, the client developed a cough. Subsequently over a period of months the client also developed lethargy, shortness of breath, weakness, collapse, hypokalemia, vision loss, hearing loss in her right ear, muscle tremors, and elevated blood diethyl phosphate levels. The reporter indicated his client consulted with multiple medical professionals and was diagnosed with triple reflex brain imbalance, severe brain inflammation, and chronic inflammatory response. No additional information is available.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

1-55708960 - The reporter indicated his client's apartment had dangerous levels of toxic mold and the client was diagnosed with a mold illness.