Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-3902
2. Registrant Information.
Registrant Reference Number: 1650663
Registrant Name (Full Legal Name no abbreviations): Bayer CropScience Inc.
Address: 160 QUARRY PARK BLVD. SE Suite 200
City: CALGARY
Prov / State: AB
Country: Canada
Postal Code: T2C 3G3
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
20-JUL-15
5. Location of incident.
Country: UNITED STATES
Prov / State: MICHIGAN
6. Date incident was first observed.
12-JUL-15
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. 72155-19
Product Name: Brush Killer Plus Concentrate
- Active Ingredient(s)
- TRICLOPYR TRIETHYLAMINE SALT
- Guarantee/concentration 8.8 %
7. b) Type of formulation.
Liquid
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 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: >64 yrs / > 64 ans
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
- Symptom - Memory loss
- Symptom - Seizure
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Yes
6. a) Was the person hospitalized?
Yes
6. b) For how long?
2
Day(s) / Jour(s)
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Application
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.
Skin
11. What was the length of exposure?
<=15 min / <=15 min
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.)
7/20/2015 Caller applied the product on 7/11/2015 by painting it on poison ivy with a small brush. One drop of the product dripped on her foot, and she washed the area about an hour after exposure. She did not develop any symptoms at the site of contact. On 7/12/2015 caller had a several hour stretch of time that she could not remember, and went to the emergency room for evaluation. Caller does not recall if any treatments were performed in the emergency room, and she was admitted to the hospital for 2 days. Caller was told that her blood pressure was low, but could not provide any information on tests done or treatments provided. Caller was given a diagnosis of global transient amnesia at discharge. After discharge caller was given magnetic resonance imaging and an electroencephalogram, which showed seizure activity in the left hemisphere. She will be seeing a neurologist tomorrow for the magnetic resonance imaging results.
To be determined by Registrant
14. Severity classification.
Major
15. Provide supplemental information here.