Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-0884
2. Registrant Information.
Registrant Reference Number: 1480422
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.
Domestic Animal
4. Date registrant was first informed of the incident.
10-OCT-14
5. Location of incident.
Country: UNITED STATES
Prov / State: CALIFORNIA
6. Date incident was first observed.
06-OCT-14
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. 432-1514
Product Name: Suspend Polyzone
- Active Ingredient(s)
- DELTAMETHRIN
- Guarantee/concentration 4.75 %
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: Res. - Out Home / Rés - à l'ext.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?
Yes
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Other / Autre
specify Exotic
3. Breed
Rabbit
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
2
7. Weight (provide a range if necessary )
7.00
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
<=15 min / <=15 min
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
12. How long did the symptoms last?
Persisted until death
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
Died
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
10/10/2014 Caller reports that products were applied by a pest control operator on 10/6/2014 for a cockroach infestation in their yard. The product was diluted to 0.25 ounces per gallon, and a total of 3 gallons was applied for the entire property. Caller was not present for the application, though reports that it was a ground level application including the area around and potentially under the wire mesh rabbit cage that was about 12 to 18 inches off of the ground. Caller noted that there was a smell or odor in the yard following the application that stayed for part of that afternoon. The rabbit was last seen alive just prior to application, and was found dead the following morning (10/7/2014). The rabbit was found with blood in and around the nose and mouth area.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here