Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-1174
2. Registrant Information.
Registrant Reference Number: x
Registrant Name (Full Legal Name no abbreviations): x
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: ONTARIO
6. Date incident was first observed.
11-JAN-12
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:
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: Animal / Usage sur un animal domestique
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Permethrin was detected on the hair sample collected.
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
Medical Professional
2. Type of animal affected
Cat / Chat
3. Breed
Domestic Short Hair
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
7
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Skin
9. What was the length of exposure?
>2 hrs <=8 hrs / >2 h <=8 h
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Nervous and Muscular Systems
- Symptom - Muscle tremors
- Symptom - Seizure
- Symptom - Recumbent
- Gastrointestinal System
- Symptom - Fecal incontinence
- Specify - feces oozing from rectum
- Blood
- Symptom - Bleeding
- Specify - bleeding from mouth
12. How long did the symptoms last?
Unknown / Inconnu
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
Euthanised / Euthanasie
16. How was the animal exposed?
Treatment / Traitement
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
"Mojo" - 7yr, DSH F(S). Presented Jan.11/12 for seizuring all night long, presented in later recumbency, bleeding from mouth, feces oozing from rectum, tremoring. Neurological signs, possible DIC. Euthanized, Euthanyl 3cc IV 11am. Hartz case #1-28617703. Body sent to U of (name) for necropsy. Permethrin was detected on the hair sample collected."Madeleine" - 6yr, DSH F(S). Applied Hartz product, hair sample sent for analysis - no permethrin ws detected. No adverse reaction to product - Madeleine in good health. Reporting cases as requested. Please contact the hospital with any questions you may have.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Not Applicable
19. Provide supplemental information here