Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2016-4721
2. Registrant Information.
Registrant Reference Number: 1-44912215
Registrant Name (Full Legal Name no abbreviations): Bayer CropScienc Inc
Address: Suite 200, 160 Quarry Park Blvd SE
City: Calgary
Prov / State: AB
Country: Canada
Postal Code: T2C 3G3
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
19-JUL-16
5. Location of incident.
Country: UNITED STATES
Prov / State: CALIFORNIA
6. Date incident was first observed.
05-JUL-16
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)
PMRA Registration No.
PMRA Submission No.
EPA Registration No. Unknown
Product Name: Sevin (non-specific)
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. - Out Home / Rés - à l'ext.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?
No
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: >64 yrs / > 64 ans
3. List all symptoms, using the selections below.
System
- Respiratory System
- Symptom - Coughing up blood
- Symptom - Pneumonia
4. How long did the symptoms last?
>8 hrs <=24 hrs / > 8 h < = 24 h
5. Was medical treatment provided? Provide details in question 13.
Yes
6. a) Was the person hospitalized?
Yes
6. b) For how long?
Unknown
7. Exposure scenario
Non-occupational
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.
Respiratory
11. What was the length of exposure?
>15 min <=2 hrs / >15 min <=2 h
12. Time between exposure and onset of symptoms.
>24 hrs <=3 days / >24 h <=3 jours
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.)
7/19/2016 2:23:10 PM Sevin fine mist sprayer EPA Reg: Caller doesn't have the product with her. Hx: Caller's elderly neighbor was using the product for about an hour 2 weeks ago. The next day he went to the hospital coughing up blood and has been hospitalized ever since. He now has pneumonia, too. He uses this product every year around this time. A few months before this happened, he was diagnosed with aplastic anemia and he needs a bone marrow transplant, but this recent illness is delaying that. Could this product have caused his symptoms?A:-Symptoms from a toxicity of this product occur withina few minutes to up to 4 hours later.-I would not expect the product to cause the clinical signs mentioned.-The product may have irritated an underlying condition, but unlikely to cause it.-Please have the gentleman's doctor call us if they have any questions.
To be determined by Registrant
14. Severity classification.
Major
15. Provide supplemental information here.