Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-3358

2. Registrant Information.

Registrant Reference Number: 2011CP045US0009950

Registrant Name (Full Legal Name no abbreviations): Bayer Inc

Address: 77 Belfield Rd

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.

15-JUL-11

5. Location of incident.

Country: UNITED STATES

Prov / State: UNKNOWN

6. Date incident was first observed.

11-APR-11

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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. Unknown

Product Name: Cylence

• Active Ingredient(s)
  • CYFLUTHRIN
    • Guarantee/concentration 1 %

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7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Animal / Usage sur un animal domestique

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Caller states that 3-4 days ago his son used this product on a head of cattle.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

No

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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Numbness
  • Symptom - Fainting
  • Specify - passed out

4. How long did the symptoms last?

>8 hrs <=24 hrs / > 8 h < = 24 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

Unknown

8. How did exposure occur? (Select all that apply)

Application

What was the activity? applied pesticide to cattle

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.

>3 days <=1 wk / >3 jours <=1 sem

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.)

4/15/2011 8:25:17 PM: Caller states that 3-4 days ago his son used this product on a head of cattle. This evening his son has lost feeling from the waist down, and passed out. He is currently being transferred to the emergency clinic. Update 22.04.2011: They did not take [son]. to see MD. Instead he drank a bunch of Gatorade and went to bed. He woke up the next day and felt fine. His dad thinks he was just exhausted and needed rest. He is now ASX. No further information is expected.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.