Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2020-0389

2. Registrant Information.

Registrant Reference Number: 2551767

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.

03-NOV-19

5. Location of incident.

Country: UNITED STATES

Prov / State: LOUISIANA

6. Date incident was first observed.

15-OCT-19

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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 432-763

Product Name: Suspend SC

• Active Ingredient(s)
  • DELTAMETHRIN
    • Guarantee/concentration 4.75 %

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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: Garage

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

• Blood
  • Symptom - Other
  • Specify - Blood clot

• Cardiovascular System
  • Symptom - Hypotension

• Skin
  • Symptom - Bruises
  • Symptom - Erythema
  • Symptom - Irritated skin
  • Symptom - Discolouration
  • Symptom - Other
  • Specify - infection under the skin

• General
  • Symptom - Discomfort

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)

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>1 wk <=1 mo / > 1 sem < = 1 mois

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.)

11/3/2019 Caller applied the product on 10/12/2019 in his garage. Caller states he could of come in contact with the product via his skin. He has a bad habit of chewing his fingernails and reports there are open sores under his fingernails that the product may have gotten into. He states he did not wash up until later that day. His symptoms felt like a sting at first the same weekend that the product was used. Since then he has developed some blood circulation issues. He has been to several different doctors and to the emergency room twice, with no reasoning behind the symptoms. His regular physician couldn't pinpoint where the symptoms are coming from, and an overnight clinic twice could not find a pulse in his right wrist. His symptoms include low blood pressure, discoloration under his nails, skin discoloration, and bruising out of nowhere with extreme discomfort. He has a nerve conductive study and a computerized tomography scan scheduled at the end of the month. 11/29/2019 Attempted call back to the original caller. A message was left requesting follow up information. Caller is returning previous message. Caller had a computerized tomography scan with dye, electromyography, and an ultrasound. He was found to have a blood clot in his right hand. He was advised to take baby aspirin. He also had an infection under his skin, and was prescribed an antibiotic. The doctor thinks the blood clot came from trauma.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.