Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-4824
2. Registrant Information.
Registrant Reference Number: 2066587
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
Environment
4. Date registrant was first informed of the incident.
30-JUN-17
5. Location of incident.
Country: UNITED STATES
Prov / State: CONNECTICUT
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)
PMRA Registration No.
PMRA Submission No.
EPA Registration No. 432-1373
Product Name: Tempo SC 1% Dust
- Active Ingredient(s)
- CYFLUTHRIN
- Guarantee/concentration 1 %
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. - 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 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 III: Domestic Animal Incident Report
1. Source of Report
Other
2. Type of animal affected
Bird / Oiseau
3. Breed
Unknown
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
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
Unknown / Inconnu
11. List all symptoms
System
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
No
14. a) Was the animal hospitalized?
Unknown
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
6/30/2017 Caller is a pest control operator who was contacted by a customer who states that product was applied to the eaves of the home on 6/26/2017. The customer has noticed dead woodpeckers today.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
Subform IV: Environment (includes plants insects and wildlife)
1. Type of organism affected
Bird - Songbird / Oiseau - Chanteur
2. Common name(s)
Woodpecker
3. Scientific name(s)
Unknown
4. Number of organisms affected
Unknown
5. Description of site where incident was observed
Fresh water
Terrestrial
Salt Water
6. Check all symptoms that apply
Death
7. Describe symptoms and outcome (died, recovered, etc.).
8. a) Was the incident a result of (select all that apply)
N/A
Unknown
8. b) i) How many times has the product been applied this year?
8. b) ii) What was the date of the last application?
9. Did it rain
9. a) During application?
No
9. b) Up to 3 days after application?
No
10. a) Was there a buffer zone?
No
10. b) What type?
10. c) What was the size of the buffer zone?
11. a) Were environmental samples collected and analysed?
No
To be determined by Registrant
12. Severity classification (if there is more than one possible classification, select the most severe)
Major
13. Please provide supplemental information here