Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-5890
2. Registrant Information.
Registrant Reference Number: 1248618
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.
Human
4. Date registrant was first informed of the incident.
18-SEP-13
5. Location of incident.
Country: CANADA
Prov / State: NOVA SCOTIA
6. Date incident was first observed.
18-JUL-13
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)
PMRA Registration No.
PMRA Submission No.
EPA Registration No. Unknown
Product Name: Movento (unknown formula)
PMRA Registration No.
PMRA Submission No.
EPA Registration No. Unknown
Product Name: Bravo
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
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?
Yes
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.
System
- Liver
- Symptom - Elevated liver enzymes
- Respiratory System
- Symptom - Respiratory irritation
- Symptom - Shortness of breath
- Skin
- Symptom - Itchy skin
- Symptom - Paresthesia
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Yes
6. a) Was the person hospitalized?
No
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Drift from the application site
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
None
10. Route(s) of exposure.
Respiratory
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.)
9/18/2013: Caller states that he lives next to a farmer, whose field reaches the limit of caller's garage. About around August 1, the farmer applied a mixture of the products to an area just behind the garage. That day, caller approached the area, and found that he could smell a chemical odor. He then left the area. He has since had shortness of breath and little endurance. He also has itching on his chest when he walks quickly, and feels like he has needles in his chest. He was seen by MD about 2-3 wks ago, and had pulmonary function tests performed on 9/13. Tests have been inconclusive, but some sort of liver enzyme tests have been found to be high but he is unsure what the test was or the results. No diagnosis has yet been made. He has not been prescribed any medications. The caller only knows of the product brand as Movento. He does not have the label information or registration number.
To be determined by Registrant
14. Severity classification.
Moderate
15. Provide supplemental information here.