Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-4972

2. Registrant Information.

Registrant Reference Number: 1-41157688

Registrant Name (Full Legal Name no abbreviations): Bayer CropScienc Inc

Address: Suite 200, 160 Quarry Park Blvd SE

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.

05-JUL-15

5. Location of incident.

Country: UNITED STATES

Prov / State: TEXAS

6. Date incident was first observed.

28-JUN-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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 432-1211-71004

Product Name: Sevin Ready to Use Bug Killer Spray

• Active Ingredient(s)
  • CARBARYL
    • Unknown

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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 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: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Irritated throat

• Renal System
  • Symptom - Other
  • Specify - Infection, Unable to determine

• General
  • Symptom - Malaise

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

Non-occupational

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

Contact with treated area

Amount of time between application and contact 1

Hour(s) / Heure(s)

What was the activity? Please refer to field 13.

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

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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.)

7/5/2015 2:37:35 PM Garden Sevin RTU SprayEPA 432-1211-71004Hx: Caller reports that she applied the product last Sunday. An hour later, her adult son touched wet product. The following night, her son had significant throat irritation and could not swallow. Her son ended up going to the hospital where they also discovered he had a kidney infection and is generally very ill. The doctors have not been able to diagnose him. A: -Product contains an insecticide called Carbaryl -A touch, taste, or lick of the product is unlikely to result in any health concerns. -Dermal contact may cause dermal irritation or redness, and contact with the mouth may cause a temporary bad taste.-The symptoms you are describing are not consistent with product exposure.-CB prn

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.