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Consumer Product Safety

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)

  • Active Ingredient(s)
    • CARBARYL

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.