Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2022-0600
2. Registrant Information.
Registrant Reference Number: 3111659
Registrant Name (Full Legal Name no abbreviations): Bayer CropScience Inc.
Address: 160 Quarry Park Boulevard 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.
10-NOV-21
5. Location of incident.
Country: CANADA
Prov / State: MANITOBA
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)
PMRA Registration No. 32524
PMRA Submission No.
EPA Registration No.
Product Name: TEMPRID SC INSECTICIDE
- Active Ingredient(s)
- BETA-CYFLUTHRIN
- IMIDACLOPRID
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. - In Home / Rés. - à l'int. 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: Female
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Gastrointestinal System
- Symptom - Stomach pain
- Symptom - Nausea
- Nervous and Muscular Systems
- Symptom - Difficulty talking
- Gastrointestinal System
- Symptom - Other
- Specify - Popping in stomach
- Symptom - Other
- Specify - Stomach pressure
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?
No
6. b) For how long?
Unknown
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
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
Other
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
None
10. Route(s) of exposure.
Unknown
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
>30 min <=2 hrs / >30 min <=2 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.)
11/10/2021 Caller reports that a pest control company sprayed the product in her home this morning. She re-entered the home about 8 hours after the application. Caller developed popping in her stomach and some pressure in her stomach about an hour prior to the call. Caller was having a difficult time talking on the phone, and says she was just recently discharged from the hospital. 11/11/2021 Attempted call back to the original caller. A message was left requesting follow up information.
To be determined by Registrant
14. Severity classification.
Minor
15. 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.