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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-1012
2. Registrant Information.
Registrant Reference Number: 517807
Registrant Name (Full Legal Name no abbreviations): Bayer CropScience Inc.
Address: #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.
14-AUG-095. Location of incident.
Country: CANADA
Prov / State: BRITISH COLUMBIA
6. Date incident was first observed.
11-AUG-09Product 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. 27688 PMRA Submission No. EPA Registration No.
Product Name: ALIETTE FUNGICIDE (Canada)
- Active Ingredient(s)
- FOSETYL-AL
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: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Red skin
4. How long did the symptoms last?
>24 hrs <=3 days / >24 h <=3 jours
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
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.
Respiratory
11. What was the length of exposure?
<=15 min / <=15 min
12. Time between exposure and onset of symptoms.
>8 hrs <=24 hrs / > 8 h < = 24 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.)
8/14/2009 Caller is a co-worker who states that an employee was soldering dried fungicide product off the piping of another machine. Caller states his co-worker was exposed to the fumes from this product for about 2 hours, 3 days ago. He wore no respiratory or facial protection at the time. Caller states his co-worker had an extremely red face afterward that lasted about 2 days after being around this product.
To be determined by Registrant
14. Severity classification.
Minor
