Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2020-0380
2. Registrant Information.
Registrant Reference Number: 2470273
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.
28-JUN-19
5. Location of incident.
Country: CANADA
Prov / State: SASKATCHEWAN
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. 30922
PMRA Submission No.
EPA Registration No.
Product Name: NAVIUS FLEX HERBICIDE
- Active Ingredient(s)
- AMINOCYCLOPYRACHLOR
- 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: Trees outdoors
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.
Yes
6. a) Was the person hospitalized?
No
6. b) For how long?
Unknown
7. Exposure scenario
Occupational
8. How did exposure occur? (Select all that apply)
Application
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
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.
Respiratory
11. What was the length of exposure?
>3 days <=1 wk / >3 jours <=1 sem
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.)
6/28/2019 Caller is a sprayer contractor and has been applying product to trees outdoors 12 hours per day for the past 2 to 4 days. Yesterday evening, he developed dizziness and pain in his knee. He mentioned that the had a tick bite earlier this week. 7/1/2019 Call back to the original caller for follow up. He was seen in the emergency room, and was told that his symptoms were caused by an ear problem and were unrelated to the product use. This may have been either a disruption in the small hairs in the ear or an ear infection. He was treated with antibiotics and Gravol. No treatments were given for the joint pain.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.