Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-3227
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: ALBERTA
6. Date incident was first observed.
15-APR-13
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. 27661
PMRA Submission No.
EPA Registration No.
Product Name: K9 ADVANTIX 20 FLEA AND TICK ADULTICIDE
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
1
Units: mL
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).
Amount of pesticde applied : 1.0ml. Site pesticide was applied: Dog (4 spots along back). Method of application:spot on treatment
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
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Cairn Terrier x West Highland Terrier
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
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- General
- Symptom - Discomfort
- Specify - uncomfortable
12. How long did the symptoms last?
>3 days <=1 wk / >3 jours <=1 sem
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
Fully Recovered / Complètement rétabli
16. How was the animal exposed?
Treatment / Traitement
specify Dog was treated with pesticide (spot-on treatment)
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Paresthesia that lasted 48hrs after treatment. The location of paresthesia was on skin where treatment was given. Bathed dog after 24hrs, but that did not improve symptom. The 48hrs following the initial 48hrs of paresthesia, dog was uncomfortable, but had shown improvement. Lot number of product: KP071NW KP070T6
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Not Applicable
19. Provide supplemental information here