Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-5353

2. Registrant Information.

Registrant Reference Number: 1668964

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.

18-AUG-15

5. Location of incident.

Country: UNITED STATES

Prov / State: FLORIDA

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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 432-1235

Product Name: Permanone 30-30 (1 gal)

• Active Ingredient(s)
  • PERMETHRIN
    • Guarantee/concentration 30 %
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration 30 %

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. Unknown

Product Name: Other Unspecified Non-Company Products

• Active Ingredient(s)

---

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: Pub. Area - Outdoor/Zone publique - ext

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.

Other

2. Demographic information of data subject

Sex: Male

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

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Decreased vision
  • Symptom - Other
  • Specify - Heterochromia

• Gastrointestinal System
  • Symptom - Other
  • Specify - Non Specific dental problems

• General
  • Symptom - Cancer
  • Specify - Oral malignant tumors

• Nervous and Muscular Systems
  • Symptom - Headache
  • Symptom - Other
  • Specify - Learning disability

• Renal System
  • Symptom - Other
  • Specify - Gynecomastia

4. How long did the symptoms last?

>2 mos and <=6mos />2 mois et <=6mois

5. Was medical treatment provided? Provide details in question 13.

Yes

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

Drift from the application site

Poisoning from ingestion of the pesticide

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

Oral

11. What was the length of exposure?

>1 mo <= 6 mos / > 1 mois < = 6 mois

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.)

8/18/2015 Caller lives on an island where many residents collect drinking water from rain on rooftops into cisterns. The county fogs and sprays to control mosquitoes. After this is done, caller can see a sheen on the surface of the water in his cistern. They have been spraying these products for his son's entire life. He has had a water sample sent for testing, but the results will take 3 months. At age (name), his son began developing cancerous tumors inside of his mouth which have been removed. His son is now (age), and has regular headaches, gynecomastia, eye problems, change in eye color in one eye 1 year ago, and learning disabilities. He began buying drinking water and now uses a water filter. Caller is wondering if contaminated water may be the cause of his son's illnesses.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.