Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-2002
2. Registrant Information.
Registrant Reference Number: x
Registrant Name (Full Legal Name no abbreviations): Wildlife Biologist, investigating poisoining incident
Address: x
City: x
Prov / State: x
Country: x
Postal Code: X
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
5. Location of incident.
Country: CANADA
Prov / State: BRITISH COLUMBIA
6. Date incident was first observed.
09-JAN-11
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.
PMRA Submission No.
EPA Registration No.
Product Name:
- Active Ingredient(s)
- ALDICARB
- BENDIOCARB
- CARBOFURAN
- DISULFOTON
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: Unknown / Inconnu
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Suspect intentional bait, given location/time of year
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Unknown
Subform III: Domestic Animal Incident Report
1. Source of Report
Other
2. Type of animal affected
Dog / Chien
3. Breed
blue heeler x border collie
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Blood
- Symptom - Bleeding
- Specify - Blood coming from nose
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
16. How was the animal exposed?
Accidental ingestion/Ingestion accident.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Dog vomited outside in a couple of different locations, brought into residence, dog died within 45 minutes, dog was put back outside and 10 minutes later owner observed blood coming from it's nose. Suspected inadvertently [exposure].Stomach contents of dog analyzed for suite of OP/Carbamate pesticides. Detected: Carbofuran 507 ppm; carbofuran 3-OH 1.53 ppm; bendiocarb 33 ppm; aldicarb 3.61 ppm; aldicarb sulfoxide 0.18 ppm; disulfoton 1.62 ppm
BC Wild Bird Mortality Investigation # Investigated in conjunction with two magpie found dead in the same area on 6-Feb-11. The residents new puppy had eaten one of the magpie (feathers found in dog house) & was subsequently sick (though recovered). BCMAL AHL examined intact magpie - diagnosis: not specified (brain cholinsterase within normal level for species, 21.9 umol/min/g, so pesticides not suspected).
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Not Applicable
19. Provide supplemental information here