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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2018-0866
2. Registrant Information.
Registrant Reference Number: 2081935
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.
26-JUL-175. Location of incident.
Country: CANADA
Prov / State: NEW BRUNSWICK
6. Date incident was first observed.
26-JUL-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. Unknown
Product Name: Navius Herbicide
- Active Ingredient(s)
- METSULFURON-METHYL
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: Other / Autre
Préciser le type: Outdoor area
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 II: Human Incident Report (A separate form for each person affected)
1. Source of Report.
Medical Professional
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 - Dizziness
- Skin
- Symptom - Rash
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?
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
Other
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.
Unknown
11. What was the length of exposure?
<=15 min / <=15 min
12. Time between exposure and onset of symptoms.
>2 hrs <=8 hrs / > 2 h < = 8 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.)
7/26/2017 Caller is a doctor at a clinic with 2 patients who present with dizziness. A licensed pest control operator flew over the area in a plane dispensing product. No obvious exposure was noted at the time. Examination of both patients was unremarkable. They complained of a foul taste in their mouths, and caller released the patients with a prescription for Peridex mouth rinse. Caller verified that there was a helicopter scheduled to apply the product today, but they are not certain this is the plane the patients were referring to or that this is the product in question. 7/28/2017 Call back to the original caller for follow up. He saw both patients yesterday. The male patient had a mild rash, and caller prescribed hydrocortisone cream. Caller does not believe the rash was related to the product. Both patients are well today.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
Subform II: Human Incident Report (A separate form for each person affected)
1. Source of Report.
Medical Professional
2. Demographic information of data subject
Sex: Female
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
- Symptom - Dizziness
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?
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
Other
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.
Unknown
11. What was the length of exposure?
<=15 min / <=15 min
12. Time between exposure and onset of symptoms.
>2 hrs <=8 hrs / > 2 h < = 8 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.)
7/26/2017 Caller is a doctor at a clinic with 2 patients who present with dizziness. A licensed pest control operator flew over the area in a plane dispensing product. No obvious exposure was noted at the time. Examination of both patients was unremarkable. They complained of a foul taste in their mouths, and caller released the patients with a prescription for Peridex mouth rinse. Caller verified that there was a helicopter scheduled to apply the product today, but they are not certain this is the plane the patients were referring to or that this is the product in question. 7/28/2017 Call back to the original caller for follow up. He saw both patients yesterday. The male patient had a mild rash, and caller prescribed hydrocortisone cream. Caller does not believe the rash was related to the product. Both patients are well today.
To be determined by Registrant
14. Severity classification.
Minor
