Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-6028

2. Registrant Information.

Registrant Reference Number: 1021813

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.

09-AUG-12

5. Location of incident.

Country: CANADA

Prov / State: NOVA SCOTIA

6. Date incident was first observed.

03-AUG-12

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. 25673      PMRA Submission No.       EPA Registration No.

Product Name: Tempo Ultra WP

• Active Ingredient(s)
  • CYFLUTHRIN

---

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: Other / Autre

Préciser le type: office

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.

Other

2. Demographic information of data subject

Sex: Male

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

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Blurred vision
  • Symptom - Burn on the eye
  • Symptom - Irritated eye

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

Occupational

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

Contact with treated area

Amount of time between application and contact 12

Hour(s) / Heure(s)

What was the activity? Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding the activity

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.

Unknown

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.)

8/9/2012 Caller is a manager at business where product was applied in the office by a pest control company on 8/7/12. The employees were out of the office for 12 hours following application. There was obvious product residue on desks. Last night, one employee who says she is allergic to pesticides developed an unknown reaction and left work to go to an outpatient clinic. Caller has no further information on the employees condition. A second employee touched a phone cord and then rubbed his eyes. He developed blurriness and ocular irritation, and rinsed his eyes at work before going to be evaluated by a doctor. 8/10/2012 Callback attempted to the original caller. A message was left requesting follow up information. 8/13/2012 Caller is the supervisor of the original caller returning the previous message. The second employee was treated for a chemical burn, and has since returned to work. 19 other employees in the office developed respiratory irritation on the same day and left the area, and 4 other employees were unaffected.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

Unknown / Inconnu

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

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Contact with treated area

Amount of time between application and contact 12

Hour(s) / Heure(s)

What was the activity? Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding the activity

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>8 hrs <=24 hrs / > 8 h < = 24 h

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.)

8/9/2012 Caller is a manager at business where product was applied in the office by a pest control company on 8/7/12. The employees were out of the office for 12 hours following application. There was obvious product residue on desks. Last night, one employee who says she is allergic to pesticides developed an unknown reaction and left work to go to an outpatient clinic. Caller has no further information on the employees condition. A second employee touched a phone cord and then rubbed his eyes. He developed blurriness and ocular irritation, and rinsed his eyes at work before going to be evaluated by a doctor. 8/10/2012 Callback attempted to the original caller. A message was left requesting follow up information. 8/13/2012 Caller is the supervisor of the original caller returning the previous message. The second employee was treated for a chemical burn, and has since returned to work. 19 other employees in the office developed respiratory irritation on the same day and left the area, and 4 other employees were unaffected.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Contact with treated area

Amount of time between application and contact 12

Hour(s) / Heure(s)

What was the activity? Please REfer to Field 13 on Subform II or field 17 of Subform III for details

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 h

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.)

8/9/2012 Caller is a manager at business where product was applied in the office by a pest control company on 8/7/12. The employees were out of the office for 12 hours following application. There was obvious product residue on desks. Last night, one employee who says she is allergic to pesticides developed an unknown reaction and left work to go to an outpatient clinic. Caller has no further information on the employees condition. A second employee touched a phone cord and then rubbed his eyes. He developed blurriness and ocular irritation, and rinsed his eyes at work before going to be evaluated by a doctor. 8/10/2012 Callback attempted to the original caller. A message was left requesting follow up information. 8/13/2012 Caller is the supervisor of the original caller returning the previous message. The second employee was treated for a chemical burn, and has since returned to work. 19 other employees in the office developed respiratory irritation on the same day and left the area, and 4 other employees were unaffected.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Contact with treated area

Amount of time between application and contact 12

Hour(s) / Heure(s)

What was the activity? Please refer to field 13 on subform II or field 17 of subform III for details

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 h

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.)

8/9/2012 Caller is a manager at business where product was applied in the office by a pest control company on 8/7/12. The employees were out of the office for 12 hours following application. There was obvious product residue on desks. Last night, one employee who says she is allergic to pesticides developed an unknown reaction and left work to go to an outpatient clinic. Caller has no further information on the employees condition. A second employee touched a phone cord and then rubbed his eyes. He developed blurriness and ocular irritation, and rinsed his eyes at work before going to be evaluated by a doctor. 8/10/2012 Callback attempted to the original caller. A message was left requesting follow up information. 8/13/2012 Caller is the supervisor of the original caller returning the previous message. The second employee was treated for a chemical burn, and has since returned to work. 19 other employees in the office developed respiratory irritation on the same day and left the area, and 4 other employees were unaffected.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Contact with treated area

Amount of time between application and contact 12

Hour(s) / Heure(s)

What was the activity? Please refer to field 13 on subform II and field 17 on subform III for details

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 h

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.)

8/9/2012 Caller is a manager at business where product was applied in the office by a pest control company on 8/7/12. The employees were out of the office for 12 hours following application. There was obvious product residue on desks. Last night, one employee who says she is allergic to pesticides developed an unknown reaction and left work to go to an outpatient clinic. Caller has no further information on the employees condition. A second employee touched a phone cord and then rubbed his eyes. He developed blurriness and ocular irritation, and rinsed his eyes at work before going to be evaluated by a doctor. 8/10/2012 Callback attempted to the original caller. A message was left requesting follow up information. 8/13/2012 Caller is the supervisor of the original caller returning the previous message. The second employee was treated for a chemical burn, and has since returned to work. 19 other employees in the office developed respiratory irritation on the same day and left the area, and 4 other employees were unaffected.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Contact with treated area

Amount of time between application and contact 12

Hour(s) / Heure(s)

What was the activity? please refer to field 13 or field 17 of subform III for details

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 h

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.)

8/9/2012 Caller is a manager at business where product was applied in the office by a pest control company on 8/7/12. The employees were out of the office for 12 hours following application. There was obvious product residue on desks. Last night, one employee who says she is allergic to pesticides developed an unknown reaction and left work to go to an outpatient clinic. Caller has no further information on the employees condition. A second employee touched a phone cord and then rubbed his eyes. He developed blurriness and ocular irritation, and rinsed his eyes at work before going to be evaluated by a doctor. 8/10/2012 Callback attempted to the original caller. A message was left requesting follow up information. 8/13/2012 Caller is the supervisor of the original caller returning the previous message. The second employee was treated for a chemical burn, and has since returned to work. 19 other employees in the office developed respiratory irritation on the same day and left the area, and 4 other employees were unaffected.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Contact with treated area

Amount of time between application and contact 12

Hour(s) / Heure(s)

What was the activity? Please refer to field 13 or 17 for details

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 h

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.)

8/9/2012 Caller is a manager at business where product was applied in the office by a pest control company on 8/7/12. The employees were out of the office for 12 hours following application. There was obvious product residue on desks. Last night, one employee who says she is allergic to pesticides developed an unknown reaction and left work to go to an outpatient clinic. Caller has no further information on the employees condition. A second employee touched a phone cord and then rubbed his eyes. He developed blurriness and ocular irritation, and rinsed his eyes at work before going to be evaluated by a doctor. 8/10/2012 Callback attempted to the original caller. A message was left requesting follow up information. 8/13/2012 Caller is the supervisor of the original caller returning the previous message. The second employee was treated for a chemical burn, and has since returned to work. 19 other employees in the office developed respiratory irritation on the same day and left the area, and 4 other employees were unaffected.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Contact with treated area

Amount of time between application and contact 12

Hour(s) / Heure(s)

What was the activity? please refer to field 13 or 17

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 h

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.)

8/9/2012 Caller is a manager at business where product was applied in the office by a pest control company on 8/7/12. The employees were out of the office for 12 hours following application. There was obvious product residue on desks. Last night, one employee who says she is allergic to pesticides developed an unknown reaction and left work to go to an outpatient clinic. Caller has no further information on the employees condition. A second employee touched a phone cord and then rubbed his eyes. He developed blurriness and ocular irritation, and rinsed his eyes at work before going to be evaluated by a doctor. 8/10/2012 Callback attempted to the original caller. A message was left requesting follow up information. 8/13/2012 Caller is the supervisor of the original caller returning the previous message. The second employee was treated for a chemical burn, and has since returned to work. 19 other employees in the office developed respiratory irritation on the same day and left the area, and 4 other employees were unaffected.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Contact with treated area

Amount of time between application and contact 12

Hour(s) / Heure(s)

What was the activity? please refer to field 13 or 17

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 h

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.)

8/9/2012 Caller is a manager at business where product was applied in the office by a pest control company on 8/7/12. The employees were out of the office for 12 hours following application. There was obvious product residue on desks. Last night, one employee who says she is allergic to pesticides developed an unknown reaction and left work to go to an outpatient clinic. Caller has no further information on the employees condition. A second employee touched a phone cord and then rubbed his eyes. He developed blurriness and ocular irritation, and rinsed his eyes at work before going to be evaluated by a doctor. 8/10/2012 Callback attempted to the original caller. A message was left requesting follow up information. 8/13/2012 Caller is the supervisor of the original caller returning the previous message. The second employee was treated for a chemical burn, and has since returned to work. 19 other employees in the office developed respiratory irritation on the same day and left the area, and 4 other employees were unaffected.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Contact with treated area

Amount of time between application and contact 12

Hour(s) / Heure(s)

What was the activity? please refer to field 13 or 17

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 h

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.)

8/9/2012 Caller is a manager at business where product was applied in the office by a pest control company on 8/7/12. The employees were out of the office for 12 hours following application. There was obvious product residue on desks. Last night, one employee who says she is allergic to pesticides developed an unknown reaction and left work to go to an outpatient clinic. Caller has no further information on the employees condition. A second employee touched a phone cord and then rubbed his eyes. He developed blurriness and ocular irritation, and rinsed his eyes at work before going to be evaluated by a doctor. 8/10/2012 Callback attempted to the original caller. A message was left requesting follow up information. 8/13/2012 Caller is the supervisor of the original caller returning the previous message. The second employee was treated for a chemical burn, and has since returned to work. 19 other employees in the office developed respiratory irritation on the same day and left the area, and 4 other employees were unaffected.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Contact with treated area

Amount of time between application and contact 12

Hour(s) / Heure(s)

What was the activity? refer to field 13 or 17

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 h

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.)

8/9/2012 Caller is a manager at business where product was applied in the office by a pest control company on 8/7/12. The employees were out of the office for 12 hours following application. There was obvious product residue on desks. Last night, one employee who says she is allergic to pesticides developed an unknown reaction and left work to go to an outpatient clinic. Caller has no further information on the employees condition. A second employee touched a phone cord and then rubbed his eyes. He developed blurriness and ocular irritation, and rinsed his eyes at work before going to be evaluated by a doctor. 8/10/2012 Callback attempted to the original caller. A message was left requesting follow up information. 8/13/2012 Caller is the supervisor of the original caller returning the previous message. The second employee was treated for a chemical burn, and has since returned to work. 19 other employees in the office developed respiratory irritation on the same day and left the area, and 4 other employees were unaffected.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Contact with treated area

Amount of time between application and contact 12

Hour(s) / Heure(s)

What was the activity? refer to field 13 or 17 for details

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 h

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.)

8/9/2012 Caller is a manager at business where product was applied in the office by a pest control company on 8/7/12. The employees were out of the office for 12 hours following application. There was obvious product residue on desks. Last night, one employee who says she is allergic to pesticides developed an unknown reaction and left work to go to an outpatient clinic. Caller has no further information on the employees condition. A second employee touched a phone cord and then rubbed his eyes. He developed blurriness and ocular irritation, and rinsed his eyes at work before going to be evaluated by a doctor. 8/10/2012 Callback attempted to the original caller. A message was left requesting follow up information. 8/13/2012 Caller is the supervisor of the original caller returning the previous message. The second employee was treated for a chemical burn, and has since returned to work. 19 other employees in the office developed respiratory irritation on the same day and left the area, and 4 other employees were unaffected.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Contact with treated area

Amount of time between application and contact 12

Hour(s) / Heure(s)

What was the activity? please refer to field 13 or 17 for details

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 h

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.)

8/9/2012 Caller is a manager at business where product was applied in the office by a pest control company on 8/7/12. The employees were out of the office for 12 hours following application. There was obvious product residue on desks. Last night, one employee who says she is allergic to pesticides developed an unknown reaction and left work to go to an outpatient clinic. Caller has no further information on the employees condition. A second employee touched a phone cord and then rubbed his eyes. He developed blurriness and ocular irritation, and rinsed his eyes at work before going to be evaluated by a doctor. 8/10/2012 Callback attempted to the original caller. A message was left requesting follow up information. 8/13/2012 Caller is the supervisor of the original caller returning the previous message. The second employee was treated for a chemical burn, and has since returned to work. 19 other employees in the office developed respiratory irritation on the same day and left the area, and 4 other employees were unaffected.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Contact with treated area

Amount of time between application and contact 12

Hour(s) / Heure(s)

What was the activity? please refer to field 13 or 17 for details

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 h

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.)

8/9/2012 Caller is a manager at business where product was applied in the office by a pest control company on 8/7/12. The employees were out of the office for 12 hours following application. There was obvious product residue on desks. Last night, one employee who says she is allergic to pesticides developed an unknown reaction and left work to go to an outpatient clinic. Caller has no further information on the employees condition. A second employee touched a phone cord and then rubbed his eyes. He developed blurriness and ocular irritation, and rinsed his eyes at work before going to be evaluated by a doctor. 8/10/2012 Callback attempted to the original caller. A message was left requesting follow up information. 8/13/2012 Caller is the supervisor of the original caller returning the previous message. The second employee was treated for a chemical burn, and has since returned to work. 19 other employees in the office developed respiratory irritation on the same day and left the area, and 4 other employees were unaffected.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Contact with treated area

Amount of time between application and contact 12

Hour(s) / Heure(s)

What was the activity? please refer to field 13 or 17 for details

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 h

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.)

8/9/2012 Caller is a manager at business where product was applied in the office by a pest control company on 8/7/12. The employees were out of the office for 12 hours following application. There was obvious product residue on desks. Last night, one employee who says she is allergic to pesticides developed an unknown reaction and left work to go to an outpatient clinic. Caller has no further information on the employees condition. A second employee touched a phone cord and then rubbed his eyes. He developed blurriness and ocular irritation, and rinsed his eyes at work before going to be evaluated by a doctor. 8/10/2012 Callback attempted to the original caller. A message was left requesting follow up information. 8/13/2012 Caller is the supervisor of the original caller returning the previous message. The second employee was treated for a chemical burn, and has since returned to work. 19 other employees in the office developed respiratory irritation on the same day and left the area, and 4 other employees were unaffected.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Contact with treated area

Amount of time between application and contact 12

Hour(s) / Heure(s)

What was the activity? please refer to field 13 or 17 for details

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 h

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.)

8/9/2012 Caller is a manager at business where product was applied in the office by a pest control company on 8/7/12. The employees were out of the office for 12 hours following application. There was obvious product residue on desks. Last night, one employee who says she is allergic to pesticides developed an unknown reaction and left work to go to an outpatient clinic. Caller has no further information on the employees condition. A second employee touched a phone cord and then rubbed his eyes. He developed blurriness and ocular irritation, and rinsed his eyes at work before going to be evaluated by a doctor. 8/10/2012 Callback attempted to the original caller. A message was left requesting follow up information. 8/13/2012 Caller is the supervisor of the original caller returning the previous message. The second employee was treated for a chemical burn, and has since returned to work. 19 other employees in the office developed respiratory irritation on the same day and left the area, and 4 other employees were unaffected.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Contact with treated area

Amount of time between application and contact 12

Hour(s) / Heure(s)

What was the activity? please refer to field 13 or 17 for details

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 h

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.)

8/9/2012 Caller is a manager at business where product was applied in the office by a pest control company on 8/7/12. The employees were out of the office for 12 hours following application. There was obvious product residue on desks. Last night, one employee who says she is allergic to pesticides developed an unknown reaction and left work to go to an outpatient clinic. Caller has no further information on the employees condition. A second employee touched a phone cord and then rubbed his eyes. He developed blurriness and ocular irritation, and rinsed his eyes at work before going to be evaluated by a doctor. 8/10/2012 Callback attempted to the original caller. A message was left requesting follow up information. 8/13/2012 Caller is the supervisor of the original caller returning the previous message. The second employee was treated for a chemical burn, and has since returned to work. 19 other employees in the office developed respiratory irritation on the same day and left the area, and 4 other employees were unaffected.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Contact with treated area

Amount of time between application and contact 12

Hour(s) / Heure(s)

What was the activity? please refer to field 13 or 17 for details

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 h

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.)

8/9/2012 Caller is a manager at business where product was applied in the office by a pest control company on 8/7/12. The employees were out of the office for 12 hours following application. There was obvious product residue on desks. Last night, one employee who says she is allergic to pesticides developed an unknown reaction and left work to go to an outpatient clinic. Caller has no further information on the employees condition. A second employee touched a phone cord and then rubbed his eyes. He developed blurriness and ocular irritation, and rinsed his eyes at work before going to be evaluated by a doctor. 8/10/2012 Callback attempted to the original caller. A message was left requesting follow up information. 8/13/2012 Caller is the supervisor of the original caller returning the previous message. The second employee was treated for a chemical burn, and has since returned to work. 19 other employees in the office developed respiratory irritation on the same day and left the area, and 4 other employees were unaffected.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Contact with treated area

Amount of time between application and contact 12

Hour(s) / Heure(s)

What was the activity? please refer to field 13 or 17 for details

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 h

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.)

8/9/2012 Caller is a manager at business where product was applied in the office by a pest control company on 8/7/12. The employees were out of the office for 12 hours following application. There was obvious product residue on desks. Last night, one employee who says she is allergic to pesticides developed an unknown reaction and left work to go to an outpatient clinic. Caller has no further information on the employees condition. A second employee touched a phone cord and then rubbed his eyes. He developed blurriness and ocular irritation, and rinsed his eyes at work before going to be evaluated by a doctor. 8/10/2012 Callback attempted to the original caller. A message was left requesting follow up information. 8/13/2012 Caller is the supervisor of the original caller returning the previous message. The second employee was treated for a chemical burn, and has since returned to work. 19 other employees in the office developed respiratory irritation on the same day and left the area, and 4 other employees were unaffected.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Contact with treated area

Amount of time between application and contact 12

Hour(s) / Heure(s)

What was the activity? please refer to field 13 or 17 for details

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.

Unknown

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.)

8/9/2012 Caller is a manager at business where product was applied in the office by a pest control company on 8/7/12. The employees were out of the office for 12 hours following application. There was obvious product residue on desks. Last night, one employee who says she is allergic to pesticides developed an unknown reaction and left work to go to an outpatient clinic. Caller has no further information on the employees condition. A second employee touched a phone cord and then rubbed his eyes. He developed blurriness and ocular irritation, and rinsed his eyes at work before going to be evaluated by a doctor. 8/10/2012 Callback attempted to the original caller. A message was left requesting follow up information. 8/13/2012 Caller is the supervisor of the original caller returning the previous message. The second employee was treated for a chemical burn, and has since returned to work. 19 other employees in the office developed respiratory irritation on the same day and left the area, and 4 other employees were unaffected.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Contact with treated area

Amount of time between application and contact 12

Hour(s) / Heure(s)

What was the activity? please refer to field 13 or 17 for details

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 h

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.)

8/9/2012 Caller is a manager at business where product was applied in the office by a pest control company on 8/7/12. The employees were out of the office for 12 hours following application. There was obvious product residue on desks. Last night, one employee who says she is allergic to pesticides developed an unknown reaction and left work to go to an outpatient clinic. Caller has no further information on the employees condition. A second employee touched a phone cord and then rubbed his eyes. He developed blurriness and ocular irritation, and rinsed his eyes at work before going to be evaluated by a doctor. 8/10/2012 Callback attempted to the original caller. A message was left requesting follow up information. 8/13/2012 Caller is the supervisor of the original caller returning the previous message. The second employee was treated for a chemical burn, and has since returned to work. 19 other employees in the office developed respiratory irritation on the same day and left the area, and 4 other employees were unaffected.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.