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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-2788
2. Registrant Information.
Registrant Reference Number: 2014349
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.
Domestic Animal
4. Date registrant was first informed of the incident.
31-MAR-175. Location of incident.
Country: UNITED STATES
Prov / State: NEVADA
6. Date incident was first observed.
24-MAR-17Product 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. 72155-80
Product Name: Home Pest plus Germ Killer Indoor & Outdoor Killer RTU (1 Gal)
- Active Ingredient(s)
- 2-PHENYLPHENOL (PRESENT AS SODIUM SALT)
- Guarantee/concentration .3 %
- BETA-CYFLUTHRIN
- 2-PHENYLPHENOL (PRESENT AS SODIUM SALT)
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: 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).
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?
YesSubform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Bird / Oiseau
3. Breed
Unknown
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
4
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- General
- Symptom - Death
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
No
14. a) Was the animal hospitalized?
No
14. b) How long was the animal hospitalized?
Unknown
15. Outcome of the incident
Died
16. How was the animal exposed?
Other / Autre
specify Defined point of exposure not evident or witnessed. Exposure based on speculation.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
3/31/2017 Caller's father applied the product outside of the home at the foundation and then sprayed indoors in small cracks and crevices in the kitchen and bathroom on 3/25/2017. Caller stayed in the home, but caller's father and mother left the home for 3 hours after treatment. They also removed the dog, and a pet bird was moved to a well ventilated patio for three hours as well. When they returned, they brought the animals back into the home and left again for shopping. When they returned, the bird was found dead. The dog was found lethargic, but returned to normal after 2 days. Caller and his parents had all been experiencing scratchy throats, but attributed it to seasonal allergies. When the bird died, they became concerned and later attributed the scratchy throats to the product. Caller's mother later developed vomiting, diarrhea, and a slight rash. She treated herself with Pepto Bismol. She is still experiencing these symptoms. Caller confirmed that no direct exposure to the product was witnessed. Caller states that they did open windows to ventilate after returning to the home on 3/25/2017.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
