Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2021-3039
2. Registrant Information.
Registrant Reference Number: 2969404
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
Packaging Failure
4. Date registrant was first informed of the incident.
31-MAY-21
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
31-MAY-21
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. 28179
PMRA Submission No.
EPA Registration No.
Product Name: ROUND UP ADVANCED READY-TO-USE WITH PULL 'N SPRAY APPLICATOR
- Active Ingredient(s)
- ACETIC ACID
- Guarantee/concentration 62.5 g/L
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).
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: Unknown
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Unknown
6. a) Was the person hospitalized?
Unknown
6. b) For how long?
7. Exposure scenario
Unknown
8. How did exposure occur? (Select all that apply)
Pesticide Spill
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
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
<=30 min / <=30 min
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.)
5/31/2021 Caller was spraying this product in her back yard approximately 10 minutes ago, when the cap came off and the product spilled all over her right hand. She immediately felt tingling on the hand. She rinsed off with water for approximately one minute. As soon as she rinsed off, the tingling went away.
To be determined by Registrant
14. Severity classification.
15. Provide supplemental information here.
Subform VI: Packaging Failure
1. What is the type of packaging that failed?
Bottle-plastic / Bouteille-plastique
2. Did packaging failure occur during?
Use of Product
3. Did packaging failure result in?
potential injury
potential exposure
4. Describe how the packaging failed and the surrounding circumstances, including a description of the potential injury or exposure.
5/31/2021 Caller was spraying this product in her back yard approximately 10 minutes ago, when the cap came off and the product spilled all over her right hand. She immediately felt tingling on the hand. She rinsed off with water for approximately one minute. As soon as she rinsed off, the tingling went away.
For Registrant use only
5. Provide supplemental information here.
The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews.