Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-6571

2. Registrant Information.

Registrant Reference Number: 1-42306372

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.

28-OCT-15

5. Location of incident.

Country: UNITED STATES

Prov / State: ILLINOIS

6. Date incident was first observed.

22-OCT-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. 432-1209-71004

Product Name: Sevin Ready to Use 5% Dust Bug Killer 1lb bottle

• 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. - In Home / Rés. - à l'int. maison

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?

No

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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Muscle weakness
  • Symptom - Unconsciousness

• Respiratory System
  • Symptom - Difficulty Breathing

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?

3

Day(s) / Jour(s)

7. Exposure scenario

Non-occupational

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

Drift from the application site

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.

Respiratory

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.)

10/28/2015 2:55:13 PM Sevin 5% dustHx: Caller used this product to dust poultry last Wednesday (10/21/15). The poultry were dusted outdoors and the caller was wearing gloves. When she was dusting poultry her girlfriend, (name) was sitting next to her. The following day (10/22/15) the caller was having trouble breathing and symptoms have gotten worse and worse since that time. She tried all the OTC cold medicines but nothing helped. Caller's girlfriend has been in the hospital for the past 3 days. Her main symptoms are respiratory but she also has had weakness and almost blacked out. They have run numerous blood tests but have not been able to figure out what is wrong with her. A: - Inhalation of smaller amounts of the dust may lead to respiratory irritation. Patients with respiratory irritation are more prone to secondary infections. - There is no specific antidote for this type of exposure treatment is symptomatic and supportive care. - If enough of the product is inhaled systemic toxicity is possible and the following symptoms may be seen: severe vomiting and diarrhea, watery eyes, blurred vision, headache, sweating, excess salivation, tremors (more common with small children or animals) and difficulty breathing. - Typically these symptoms are short term (only lasting about 24 hours). -Agreed with seeking medical attention at this time since you are still having trouble breathing. - There are specific blood tests that be run to check for carbamate toxicity. - Atropine is the medication that a HCP can give for a patient who is suffering from systemic toxicity to this product. - When you go to a HCP bring the product and our phone number. - Please call back if any additional concerns or questions arise. 10/28/2015 3:20:13 PM reviewed, notified client 10/30/2015 1:39:19 PM (name) (name) to (name): Left message on voicemail with case number and callback number. 11/1/2015 12:08:41 PM CB #2 LMOM with call back number (phone number) and case number asking for return call and follow-up information.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.