Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-7169

2. Registrant Information.

Registrant Reference Number: 1726170

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.

24-NOV-15

5. Location of incident.

Country: UNITED STATES

Prov / State: NEW YORK

6. Date incident was first observed.

24-SEP-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. 432-992

Product Name: Drione 1 lb

• Active Ingredient(s)
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration 10 %
  • PYRETHRINS
    • Guarantee/concentration 1 %
  • SILICA AEROGEL

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7. b) Type of formulation.

Granular

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Other / Autre

Préciser le type: Bee hive

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: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Headache

• Renal System
  • Symptom - Other
  • Specify - Unspecified Renal Disorder

• Respiratory System
  • Symptom - Shortness of breath

• Nervous and Muscular Systems
  • Symptom - Unconsciousness
  • Symptom - Dizziness

• Cardiovascular System
  • Symptom - Other
  • Specify - Unspecified cardiac disorder

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?

11

Day(s) / Jour(s)

7. Exposure scenario

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)

Chemical resistant gloves

10. Route(s) of exposure.

Skin

Respiratory

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 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.)

11/24/2015 Caller states that on 9/17/15 he applied the product to a bee nest for 30 to 45 min while at work. Within 30 minutes, he removed the nest. He was wearing gloves but no mask for respirator. He states he may have inhaled the powder, and it may have gotten on his skin. When he got back to his truck, he became dizzy and passed out. He was transported to emergency department by ambulance. He states he was unconscious from 9:30 a.m. to 6:00 p.m. When he woke up he was told he had heart and kidney problems. His kidney test was 27000, and should be 50 to 80. He does not know what test this was, or what he was diagnosed with. He states there is nothing wrong with his heart at this time. He was hospitalized from 9/17/15 to 9/28/15. He states no medications were given, only intravenous fluids. Kidney test was 4500 when he was discharged. He was advised to drink lots of water until his kidneys were back to normal. He was at the doctor earlier today for blood work, but does not have test results yet. He expects them today or tomorrow. He was having breathing problems and headaches since this happened. Breathing problems are resolved, but he still has headaches. He has not worked since this happened. 11/25/2015 Call back to the original caller for follow up information. Caller has not yet gotten the test results back.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.