Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-2901
2. Registrant Information.
Registrant Reference Number: 2010TH018
Registrant Name (Full Legal Name no abbreviations): Bayer Inc
Address: 77 Belfield Road
City: Toronto
Prov / State: ON
Country: Canada
Postal Code: M9W 1G6
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
21-JUN-10
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
16-JUN-10
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. 25130
PMRA Submission No.
EPA Registration No.
Product Name: Advantage 10
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: Female
Age: >64 yrs / > 64 ans
3. List all symptoms, using the selections below.
System
4. How long did the symptoms last?
>3 days <=1 wk / >3 jours <=1 sem
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)
Contact with treated area
Amount of time between application and contact 1
Day(s) / Jour(s)
What was the activity? casual contact with pet
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
10. Route(s) of exposure.
Skin
11. What was the length of exposure?
>24 hrs <=3 days / >24 h <=3 jours
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.)
Owner applied advantage 10 to her pet June 15 2010. The owner's mother came to visit and had contact with the pet, including having the pet lick her ankles, June 16 - 18. On or around June 16 the pet owner's mother developed a mild rash on her arms and legs. The rash was still present as of the reporting date, June 21 2010. The affected person is a heart transplant patient.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
The pet owner was advised to have her mother examined by her doctor.