Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2021-2465

2. Registrant Information.

Registrant Reference Number: 2941757

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

Address: 160 QUARRY PARK BLVD. SE Suite 130

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.

29-APR-21

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 71995-33

Product Name: ROUNDUP WEED & GRASS KILLER READY-TO-USE PLUS

• Active Ingredient(s)
  • GLYPHOSATE (PRESENT AS ISOPROPYLAMINE SALT OR ETHANOLAMINE SALT)
    • Guarantee/concentration 2 %
  • PELARGONIC ACID
    • Guarantee/concentration 2 %

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 71995-33

Product Name: ROUNDUP READY-TO-USE WEED & GRASS KILLER III

• Active Ingredient(s)
  • GLYPHOSATE
    • Unknown

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7. b) Type of formulation.

Liquid

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).

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

• Cardiovascular System
  • Symptom - Hypertension

• Renal System
  • Symptom - Renal failure

• Respiratory System
  • Symptom - Shortness of breath

• Nervous and Muscular Systems
  • Symptom - Other
  • Specify - Membranous Nephropathy

• Blood
  • Symptom - Abnormal coagulation
  • Specify - Blood clots in lungs
  • Symptom - Abnormal coagulation
  • Specify - Blood clots in heart
  • Symptom - Other
  • Specify - Unspecified blood disease

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

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?

>1 yr / > 1 an

12. Time between exposure and onset of symptoms.

>6 mos / > 6 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.)

29/04/2021 : Caller is a poor historian. Caller was very talkative, interruptive, and difficult to keep on task. Numerous attempts were made to gather need info. Caller could not be redirected.Hx: Caller reports he has been using round up since he was 17 years old. He has used it the past 40 yrs at least 2-3 times per week. Approximately 8 months ago he developed SOB. He was transported to the ER via ambulance. He reported dying 3 times, once in the ambulance on the way to the hospital, the other times while in ICU. He spent 9 days in ICU on machines that connected to his heart and lungs. He was diagnosed with blood clots in his heart and lungs, a unspecified blood disease, kidney failure and Membranous Nephropathy. The doctors told him his blood is to thick due to using round up. He had to have blood transfusions and takes blood thinners. His kidneys now operate at 10% and he has refused dialysis. He is currently taking Chemo therapy for approximately 6 months. He said the doctors told him he has 2.5 years to live. He has been contacted by attorneys telling him to sue the round up manufacturer. He verbalized several times his bother is a prosecutor. His brother will to take his case for free. He does not want to get any lawyers involved. He would like to reach a monetary settlement with the company. He reported he has documentation from his medical providers stating Round Up caused his condition. He reported he would subpoena his doctors and customers if he needs to do so. He was very repetitive. He reported having several concussions while in the military and having impaired memory. He reported having a kidney function test scheduled for later today. He also has labs scheduled but unable to specify what they are. He has two bottles of this product he purchased approximately 20 years ago. He repeatedly said the labels do not have any warnings on the label. He still has the receipt from the purchase. He agreed to email his medical records, product information, and receipts if needed. He would like to be compensated for missed time at work. He also said he wold like to know his family will be cared for when he dies.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

While the reporter has been using the product since he was 17 years old, no exposures were specifically reported. It is unknown if he was using the product as directed. While a temporal relationship exists, using the product as directed even for an extended period of time, is not expected to result in the described symptoms. Although the consumer reports his doctor believes his symptoms are due to use of Round-Up, from the information provided and lack of exposure reported it is not likely. It is unknown what other causes have been ruled out from the differential diagnoses.