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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-1900

2. Registrant Information.

Registrant Reference Number: 759870

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.

5. Location of incident.

Country: UNITED STATES

Prov / State: FLORIDA

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.

PMRA Registration No.       PMRA Submission No.       EPA Registration No. 72155-29

Product Name: Complete Insect Killer for Soil + Turf Concentrate 32 fl oz

• Active Ingredient(s)
  • CYFLUTHRIN
    • Guarantee/concentration .36 %
  • IMIDACLOPRID
    • Guarantee/concentration .72 %

7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Unknown

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.

Medical Professional

2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Cardiovascular System
  • Symptom - Arrhythmia
  • Symptom - Bradycardia
  • Symptom - Cardiac arrest

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)

Other

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?

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.)

3/5/2011 Caller is a physician treating a patient that developed heart block, heart failure, and went into cardiac arrest. The patient was put on a balloon pump, resuscitated, and had a pacemaker placed. The patient had no history of coronary artery disease prior to this episode. The patient had this product in his home and may have sprayed it in the home or yard according to another family member but this is not known for sure. The physician is not aware of any report of known exposure to the product. The exposure history appears to be based on speculation.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.