Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-3697

2. Registrant Information.

Registrant Reference Number: 798206

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

Address: 295 Henderson Drive

City: Regina

Prov / State: SK

Country: Canada

Postal Code: S4N 6C2

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

03-JUN-11

5. Location of incident.

Country: UNITED STATES

Prov / State: ILLINOIS

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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 72155-35

Product Name: Triple Action Ant Killer Ready to Use Granules 1.5 lb

• Active Ingredient(s)
  • CYFLUTHRIN
    • Guarantee/concentration .05 %

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7. b) Type of formulation.

Granular

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Res. - Out Home / Rés - à l'ext.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 III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Yorkshire Terrier (Yorkie)

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

4

7. Weight (provide a range if necessary )

11.00

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Anorexia

• General
  • Symptom - Death
  • Symptom - Lethargy

• Skin
  • Symptom - Bruises

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

No

14. a) Was the animal hospitalized?

Yes

14. b) How long was the animal hospitalized?

Unknown

15. Outcome of the incident

Died

16. How was the animal exposed?

Other / Autre

specify Defined point of exposure not evident or witnessed. Exposure based on speculation.

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

6/3/2011 Caller was gone for a couple of days, and caller's dog was in the care of someone else during that time. She relates that the product had been applied around their landscaping about one week ago. The dog had no known contact with the pesticide. The dog has been anorexic, lethargic, and developed bruising on her body in the past few days. The dog is now hospitalized, and the veterinarian believes the dog has been poisoned by rat poison given the bleeding complications. The veterinarian did not feel that the pesticide was responsible. The dog had no known exposure to the product. 6/10/2011 Callback attempted to the original caller. A message was left requesting follow up information. The original caller returned the previous message. The dog died in the clinic the day of the original call with no treatment. No necropsy was performed.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here