Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2020-3492

2. Registrant Information.

Registrant Reference Number: 32617438

Registrant Name (Full Legal Name no abbreviations): Bayer CropScience Inc.

Address: Suite 200, 160 Quarry Park Blvd S.E.

City: Calgary

Prov / State: Alberta

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.

06-AUG-20

5. Location of incident.

Country: UNITED STATES

Prov / State: MISSOURI

6. Date incident was first observed.

13-JUL-20

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. 524-445

Product Name: Roundup Herbicide

• Active Ingredient(s)
  • GLYPHOSATE
    • Guarantee/concentration 41 %

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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: Res. - Out Home / Rés - à l'ext.maison

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

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: Male

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Cardiovascular System
  • Symptom - Tachycardia

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?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

Unknown

8. How did exposure occur? (Select all that apply)

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.

Oral

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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.)

MD calling from Emergency Department calling about a x year old male who was spraying an unknown formulation of Roundup in his yard today and may have gotten a mist on his tongue. He is now in V-tach. The MD is wondering if there are any reports of this with Roundup. (City) Regional Poison Control (xRPC) discussed the product toxicity. Symptoms do not correspond with the expected response to the product. Specialist in Poison Information (SPI) concerned re: possible misinterpretation of symptoms and/or possible misidentification of product or mixed exposure. Information on glyphosate faxed for the physician. No further calls or information received in regards to this exposure.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.