Health Canada
www.hc-sc.gc.ca
Home
> Consumer Product Safety
> Pesticides & Pest Management
> Protecting Your Health & the Environment
> Public Registry
> Product Information > Disclaimer > Incident Reports " >Incident Type
Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2007-4529
2. Registrant Information.
Registrant Reference Number: 183636
Registrant Name (Full Legal Name no abbreviations): Bayer CropScience, Inc.
Address: Suite 100, 3131 114 Avenue SE
City: Calgary
Prov / State: AB
Country: Canada
Postal Code: T2Z 3X2
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
05-MAY-07
5. Location of incident.
Country: CANADA
Prov / State: MANITOBA
6. Date incident was first observed.
03-MAY-07
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. 27566
PMRA Submission No.
EPA Registration No.
Product Name: RAXIL T FLOWABLE FUNGICIDE
7. b) Type of formulation.
Application Information
8. Product was applied?
No
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
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.
Other
2. Demographic information of data subject
Sex: Male
Age: <=1 yr / < = 1 an
3. List all symptoms, using the selections below.
System
- Gastrointestinal System
- Symptom - Diarrhea
- Symptom - Vomiting
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?
No
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Other
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
None
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.)
5/5/2007 Caller's grandson has been ill with flu like sxs for the past 4-5 days with bomiting, fever, and diarrhea. He has already seen an MD who states this is a flu virus of some kind but caller just wanted to make sure that this product would not cause sxs. Only route of exposure would be from child touching dad after dad has worked with material at work A; Unlikely significant exposure occurred and unlikely sxs are related. Sxs present are classic for viral/bacterial disease as diagnosed by the patient's doctor.
To be determined by Registrant
14. Severity classification.
Moderate
15. Provide supplemental information here.