Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2019-0709
2. Registrant Information.
Registrant Reference Number: 2322860
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-OCT-18
5. Location of incident.
Country: CANADA
Prov / State: BRITISH COLUMBIA
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. 32524
PMRA Submission No.
EPA Registration No.
Product Name: TEMPRID SC INSECTICIDE
- Active Ingredient(s)
- BETA-CYFLUTHRIN
- IMIDACLOPRID
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?
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
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
Other
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
Unknown
10. Route(s) of exposure.
Unknown
11. What was the length of exposure?
>1 wk <=1 mo / > 1 sem < = 1 mois
12. Time between exposure and onset of symptoms.
>3 days <=1 wk / >3 jours <=1 sem
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.)
10/11/2018 Caller had this product applied in his home by a pest control operator 1 week ago. He was out of the home for 8 hours before returning home. After he returned home he began experiencing dizziness. He opened windows for ventilation, but this did not improve the dizziness. The dizziness will improve when he is out of the home for 6 to 7 hours, but return or worsen after returning to the home. Caller has a history of environmental vertigo that is triggered by certain smells or foods.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.