Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-0794
2. Registrant Information.
Registrant Reference Number: 1464275
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
Domestic Animal
4. Date registrant was first informed of the incident.
15-SEP-14
5. Location of incident.
Country: CANADA
Prov / State: ALBERTA
6. Date incident was first observed.
Unknown
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. 15255
PMRA Submission No.
EPA Registration No.
Product Name: Drione Drione Insecticide Powder
- Active Ingredient(s)
- PIPERONYL BUTOXIDE
- PYRETHRINS
- SILICA AEROGEL
PMRA Registration No. 25673
PMRA Submission No.
EPA Registration No.
Product Name: TEMPO 20 WP INSECTICIDE (CANADA)
PMRA Registration No.
PMRA Submission No.
EPA Registration No. Unknown
Product Name: Non-company Pyrethrin Pesticide
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: Neighbor's apartment
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: Female
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Gastrointestinal System
- Symptom - Irritated throat
- Nervous and Muscular Systems
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
Non-occupational
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
Other
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?
>1 wk <=1 mo / > 1 sem < = 1 mois
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.)
9/15/2014 Caller moved into the apartment around 8/30/2014. For the first couple of days she had dry eyes, sore throat, and nasal irritation off and on. She has also had a headache off and on since moving in. Caller's cat had diarrhea for a couple of days, and her dog had diarrhea and anorexia that resolved quickly. Caller's neighbor's apartment was treated with the products last week, and they are planning to treat her apartment.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
Unknown
4. Number of animals affected
2
5. Sex
Female
6. Age (provide a range if necessary )
2
7. Weight (provide a range if necessary )
12.00
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
>1 wk <=1 mo / > 1 sem < = 1 mois
10. Time between exposure and onset of symptoms
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
12. How long did the symptoms last?
>24 hrs <=3 days / >24 h <=3 jours
13. Was medical treatment provided? Provide details in question 17.
No
14. a) Was the animal hospitalized?
No
14. b) How long was the animal hospitalized?
Unknown
15. Outcome of the incident
Fully Recovered / Complètement rétabli
16. How was the animal exposed?
Other / Autre
specify Defined point of exposure not evident or witnessed. Exposure based on speculation.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
9/15/2014 Caller moved into the apartment around 8/30/2014. For the first couple of days she had dry eyes, sore throat, and nasal irritation off and on. She has also had a headache off and on since moving in. Caller's cat had diarrhea for a couple of days, and her dog had diarrhea and anorexia that resolved quickly. Caller's neighbor's apartment was treated with the products last week, and they are planning to treat her apartment.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
19. Provide supplemental information here
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Cock-a-poo
4. Number of animals affected
2
5. Sex
Female
6. Age (provide a range if necessary )
4
7. Weight (provide a range if necessary )
15.00
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
>1 wk <=1 mo / > 1 sem < = 1 mois
10. Time between exposure and onset of symptoms
>3 days <=1 wk / >3 jours <=1 sem
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Anorexia
- Symptom - Diarrhea
12. How long did the symptoms last?
>8 hrs <=24 hrs / > 8 h < = 24 h
13. Was medical treatment provided? Provide details in question 17.
No
14. a) Was the animal hospitalized?
No
14. b) How long was the animal hospitalized?
Unknown
15. Outcome of the incident
Fully Recovered / Complètement rétabli
16. How was the animal exposed?
Other / Autre
specify Defined point of exposure not evident or witnessed. Exposure based on speculation.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
9/15/2014 Caller moved into the apartment around 8/30/2014. For the first couple of days she had dry eyes, sore throat, and nasal irritation off and on. She has also had a headache off and on since moving in. Caller's cat had diarrhea for a couple of days, and her dog had diarrhea and anorexia that resolved quickly. Caller's neighbor's apartment was treated with the products last week, and they are planning to treat her apartment.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here