Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-6046

2. Registrant Information.

Registrant Reference Number: 2089958

Registrant Name (Full Legal Name no abbreviations): Bayer CropScience Inc.

Address: 160 QUARRY PARK BLVD. SE Suite 200

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.

09-AUG-17

5. Location of incident.

Country: UNITED STATES

Prov / State: NEW YORK

6. Date incident was first observed.

07-AUG-17

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. 2217-894-72155

Product Name: All-in-One Lawn Weed & Crabgrass Killer Ready-to-Spray

• Active Ingredient(s)
  • 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)
    • Guarantee/concentration 4.85 %
  • DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, OR SODIUM SALT)
    • Guarantee/concentration .45 %
  • QUINCLORAC
    • Guarantee/concentration 1.61 %

---

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).

Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding application.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Yes

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

• Eye
  • Symptom - Irritated eye

• Blood
  • Symptom - Abnormal coagulation
  • Specify - Blood clots in lungs

• Respiratory System
  • Symptom - Respiratory irritation

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?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

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

Application

What was the activity? Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding the activity

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?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

8/9/2017 Caller's stepfather was spraying product 2 days ago. Within 30 minutes, caller's stepfather began to develop eye irritation and lung irritation. He was seen at the emergency department. Unspecified blood tests, chest x-ray, and an unspecified scan of his chest were performed. He was found to have blood clots in his lungs, and was admitted to the hospital. Caller knows that he is receiving intravenous fluids. The treating physicians do not think that his use of the product is related to the events. 8/10/2017 Attempted call back to the original caller. A message was left requesting follow up information.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.