Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2021-0837

2. Registrant Information.

Registrant Reference Number: 2675302

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.

22-MAY-20

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

22-MAY-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. 29498      PMRA Submission No.       EPA Registration No.

Product Name: START UP HERBICIDE

• Active Ingredient(s)
  • GLYPHOSATE
    • Guarantee/concentration 540 g/L

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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: Workplace

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?

Unknown

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Malaise
  • Symptom - Other
  • Specify - Feeling depressed

• Gastrointestinal System
  • Symptom - Mouth Irritation

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Occupational

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

Application

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.

Skin

Oral

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>8 hrs <=24 hrs / > 8 h < = 24 h

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.)

5/22/2020 Caller's husband was using the product yesterday when a hose blew off of the sprayer. The product splashed into his hair, face, and mouth. It did not get into his eyes. He immediately washed the product off in the shower. Caller gave him a charcoal tablet after he got out of the shower. He came home for lunch today and reported that he felt sick. He did not provide any specific information about his symptoms. She noticed he had a decreased appetite during lunch. She gave him another charcoal capsule before he left home after lunch. 5/27/2020. Call back for follow up information, spoke to the patient. He has some mild oral irritation. He did not seek medical care. He is feeling a little depressed and still does not feel quite right. 6/4/2020 Call back to the original caller for follow up information. Caller believes stress is causing most of husband's symptoms. he is still depressed and generally does not feel well.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.