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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2821

2. Registrant Information.

Registrant Reference Number: INRI-0225

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.

5. Location of incident.

Country: UNITED STATES

Prov / State: INDIANA

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.

PMRA Registration No.       PMRA Submission No.       EPA Registration No. 264-1066

Product Name: Corvus Herbicide

• Active Ingredient(s)
  • ISOXAFLUTOLE
    • Guarantee/concentration 19 %
  • THIENCARBAZONE-METHYL

7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

9. Application Rate.

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).

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: Female

Age: >12 <=19 yrs / >12 <=19 ans

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Seizure

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?

Unknown

6. b) For how long?

7. Exposure scenario

Unknown

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

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Unknown

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>24 hrs <=3 days / >24 h <=3 jours

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.)

I just wanted to let you know that your product, Corvus, was applied to the field east of my farm two days ago. My (age) daughter is very sick because of it. Her nervous system is completely on fire. She is having seizures and she is totally "gone." I have spent the past eight years undoing all the damage done by the medical community and the fake, crap sold as "food" in the U.S. My daughter is a beautiful, young girl with a wonderful life ahead of her. However, the summer wrecks her health because of the constant barrage of toxic crap sprayed all around us. I raise most of our food because I refuse to feed my family the GMO, pesticide laden crap in the grocery store. I am tired and I'm sick of watching my children suffer. I know NO ONE at your company cares, otherwise you wouldn't poison the whole world. I am a caring, compassionate person but right now I just wish that whoever is making billions of dollars at the expense of poisoning my children would have to watch their child suffer the way mine do. I hope you sleep well at night knowing what you promote is slow genocide. I will prevail though, my farm goes up for sale next week and I will find a place away from the poisoned, toxic land where I grew up. Iam an educated woman, well versed in alternative therapies so I don't need your chemicals or your medicine. Once again I KNOW you could care less but I also believe there is a God in heaven and one day we will all stand before Him. I hope you have a good answer for the atrocities you're committing against humanity, I'm sure Hitler and Stalin did as well.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.