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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-2825

2. Registrant Information.

Registrant Reference Number: 990671

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


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. 25864      PMRA Submission No.       EPA Registration No.

Product Name: Puma Super (Canada)

  • Active Ingredient(s)

PMRA Registration No. 29615      PMRA Submission No.       EPA Registration No.

Product Name: Puma Advanced

  • Active Ingredient(s)

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

Product Name: Unspecified Dow AgroSciences herbicides

  • 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).

Site: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: Unknown

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?


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: Male

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

3. List all symptoms, using the selections below.


  • Eye
    • Symptom - Blurred vision
  • Nervous and Muscular Systems
    • Symptom - Disorientation
    • Symptom - Dizziness
    • Symptom - Headache
    • Symptom - Difficulty walking
  • Cardiovascular System
    • Symptom - Abnormally high blood pressure
    • Specify - high blood pressure

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.


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


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


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

Chemical resistant gloves


10. Route(s) of exposure.


11. What was the length of exposure?

<=15 min / <=15 min

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.)

June 14, 2012 Caller states he mixed and applied the product on his farm on June 9. Caller does not recall exposure but speculates that product may have contacted his skin during tank mixing, and spray mist may have contacted his skin and/or he may have inhaled vapors. 1 day after application he began to experience a dizzy unbalanced feeling and blurred vision after drinking one beer. He had difficulty walking. He felt he was not thinking right. 2 days after application the sxs persisted and he developed a headache, so he went to ED. He was given a CT scan and unspecified blood work. His BP was high and he was referred to his own doctor. He saw his own doctor the following day, 3 days after application, and his BP was normal. His sxs persist as of June 14 although they are better. Follow-up on June 19, 2012 Patient saw a neurologist who was unable to find anything wrong. MD did not seem to think the herbicides were involved.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.