Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2008-1078
2. Registrant Information.
Registrant Reference Number: 256198
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.
02-NOV-07
5. Location of incident.
Country: CANADA
Prov / State: BRITISH COLUMBIA
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)
PMRA Registration No.
PMRA Submission No.
EPA Registration No.
Product Name: Baygon (unspecified)
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).
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: Female
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
4. How long did the symptoms last?
>30 min <=2 hrs / >30 min <=2 h
5. Was medical treatment provided? Provide details in question 13.
No
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)
Application
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.
Respiratory
11. What was the length of exposure?
>1 mo <= 6 mos / > 1 mois < = 6 mois
12. Time between exposure and onset of symptoms.
>30 min <=2 hrs / >30 min <=2 h
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.)
11/2/2007 Caller is property owner, and reports that they had foundation treatment with product by PCO on or around 9/19/2007. Caller reports no direct exposure to product, but that there is still a strong smell inside the structure. Caller and caller's spouse each develop a headache when they enter the structure. Headaches resolve with some fresh air. They do not have exact label information available.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
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: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
4. How long did the symptoms last?
>30 min <=2 hrs / >30 min <=2 h
5. Was medical treatment provided? Provide details in question 13.
No
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)
Application
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.
Respiratory
11. What was the length of exposure?
>1 mo <= 6 mos / > 1 mois < = 6 mois
12. Time between exposure and onset of symptoms.
>30 min <=2 hrs / >30 min <=2 h
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.)
11/2/2007 Caller is property owner, and reports that they had foundation treatment with product by PCO on or around 9/19/2007. Caller reports no direct exposure to product, but that there is still a strong smell inside the structure. Caller and caller's spouse each develop a headache when they enter the structure. Headaches resolve with some fresh air. They do not have exact label information available.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.