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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-0897

2. Registrant Information.

Registrant Reference Number: 1061350

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.


Prov / State: NEW YORK

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.       PMRA Submission No.       EPA Registration No. 72155-80

Product Name: Home Pest plus Germ Killer Indoor & Outdoor Killer RTU (1 Gal)

  • Active Ingredient(s)
      • Guarantee/concentration .05 %
      • Guarantee/concentration .3 %

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.

Medical Professional

2. Demographic information of data subject

Sex: Female

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

3. List all symptoms, using the selections below.


  • Gastrointestinal System
    • Symptom - Nausea
    • Symptom - Vomiting
  • General
    • Symptom - Hemorrhage
  • Nervous and Muscular Systems
    • Symptom - Seizure
    • Symptom - Unresponsive

4. How long did the symptoms last?

Unknown / Inconnu

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)


10. Route(s) of exposure.


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.)

Oct. 22, 2012 Physician reports that a (age) y/o F with a prior history of hypertension, asthma and seizure was in her usual state of health yesterday when she began to feel progressively ill over the course of several hours. She initially experienced nausea with some vomiting and suddenly becoming unresponsive and having seizure activity (unknown if status vs. multiple repeated seizures). EMS was immediately notified and was transported to hospital. She is currently unresponsive on a ventilator and other life support. Her prior medication history consists of Lisinopril Amlodipine and Certraline. CT scan of the brain shows an intra-ventricular hemorrhage. Further consult and imaging studies by neuro-surgery group is investigating if there were underlying brain structural issues that pre-dated this event that can be identified however there is apparently no family history of such events. She remains on life support Her prognosis has been listed as "poor". Her use of the the product is unclear (if any). It is known that she had been spraying this product around the house recently due to some sort of pest infestation though other details of product use or any exposure to it are not known.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.