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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-4500

2. Registrant Information.

Registrant Reference Number: 1434031

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: CALIFORNIA

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. 72155-27

Product Name: Home Pest Control Indoor & Outdoor Insect Killer Ready-to-Use

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

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: Res. - In Home / Rés. - à l'int. maison

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.


2. Demographic information of data subject

Sex: Male

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

3. List all symptoms, using the selections below.


  • General
    • Symptom - Death
  • Nervous and Muscular Systems
    • Symptom - Headache
    • Symptom - Unresponsive

4. How long did the symptoms last?

Persisted until death

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)

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)


10. Route(s) of exposure.


11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>2 hrs <=8 hrs / > 2 h < = 8 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.)

7/30/2014 Caller is an investigator with a coroner office. He is investigating the death of a (name) year old male with a known history of alcoholism who was found dead on 7/27/2014 in a chair at home. According to available history, this product was sprayed in the patient's room (reportedly unventilated) at his parents house while he was present at about 10:00 a.m. on 7/27/2014 by his father. About 2 hours later, the patient was complaining of headaches. Around 2:00 p.m. he moved to an easy chair in another room. He was found unresponsive at 5:00 p.m. and emergency medical services were called. Resuscitation efforts were made, but he was declared dead at a local hospital. He did not regain consciousness after being found unresponsive. There is no suspicion of self harm attempt with this product or deliberate actions to injure. At present this is being investigated as an unexpected death. 8/5/2014 Attempted call back to the original caller. A message was left requesting follow up information. Follow-up again made with the Medical Examiner's office on Aug. 13 in an attempt to determine findings of the autopsy. The ME office agents reports that the cause of death is listed as 'deferred' pending the completion of a toxicology screen. The report indicates, however, that the pathologist indicates that the Bayer pesticide is was not felt to be contributory.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.