Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2019-0699
2. Registrant Information.
Registrant Reference Number: 2250630
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.
11-JUN-18
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
11-JUN-18
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. 32824
PMRA Submission No.
EPA Registration No.
Product Name: PROSARO XTR
- Active Ingredient(s)
- PROTHIOCONAZOLE
- TEBUCONAZOLE
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: Unknown 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?
Yes
Subform II: Human Incident Report (A separate form for each person affected)
1. Source of Report.
Other
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
- Nervous and Muscular Systems
- Symptom - Other
- Specify - muscles not working properly
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Unknown
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
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.
Skin
11. What was the length of exposure?
<=15 min / <=15 min
12. Time between exposure and onset of symptoms.
<=30 min / <=30 min
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.)
6/11/2018 Caller is calling for her neighbor. Neighbor was walking and was sprayed with the product as she walked by. After being sprayed, she developed tingling/numbness on the left side of her face and her left leg. She feels her body is not working correctly. She feels she cannot smile on the left and the muscles in her leg are not working properly. Neighbor looked at her face and reported the skin appeared normal and symmetrical. She showered for about 10 minutes after returning from her walk, 20 minutes after the exposure. Her symptoms are not worsening at this time.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.