Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-0620

2. Registrant Information.

Registrant Reference Number: 1202677

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-JUL-13

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

05-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)

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PMRA Registration No. 26694      PMRA Submission No.       EPA Registration No.

Product Name: LIBERTY 150 SN HERBICIDE (Canada)

• Active Ingredient(s)
  • GLUFOSINATE AMMONIUM

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7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

9. Application Rate.

Unknown

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).

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?

Unknown

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

• Eye
  • Symptom - Irritated eye

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?

Unknown

7. Exposure scenario

Occupational

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

Application

Amount of time between application and contact 0

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.

Eye

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.)

7/9/2013 Caller reports that her son works with the product and got product into his eye 4 days ago. He developed eye irritation, and rinsed his eye for 30 minutes. He was back to normal very quickly.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.