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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-0867

2. Registrant Information.

Registrant Reference Number: 885815

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.


4. Date registrant was first informed of the incident.


5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.


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. 27688      PMRA Submission No.       EPA Registration No.

Product Name: Aliette WDG Fungicide

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


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?


Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Female

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

3. List all symptoms, using the selections below.


  • Skin
    • Symptom - Irritated skin
    • Symptom - Itchy skin
    • Symptom - Rash
    • Symptom - Lesion
    • Specify - scabs

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.


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


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

Pesticide Spill

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Chemical resistant coveralls

10. Route(s) of exposure.


11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

11/16/2011 Product was mixed with water in a sprayer tank at a concentration of 4 gallons per liter with an additional wetting agent. The spray tank broke, and the product sprayed out while she was fixing it. Caller was wearing a spray suit, and the only part of her skin showing was her neck. Caller was sprayed on the back of her neck around one hour ago. Caller did not feel any symptoms right away, but began to feel itching on her neck a short time later when she went inside. Caller showered and washed the area for at least 15 minutes. Her neck is red and irritated, and has 3 or 4 bumps. 11/17/2011 Callback attempted to the original caller. A message was left requesting follow up information. 11/18/2011 Callback attempted to the original caller. A message was left requesting follow up information. The caller is returning the previous message. Caller developed a few scabs in the area, but they have since resolved. Caller is asymptomatic at this point.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.