Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-2754

2. Registrant Information.

Registrant Reference Number: 2014-23

Registrant Name (Full Legal Name no abbreviations): BASF Canada

Address: 100 Milverton, 5th floor

City: Mississauag

Prov / State: ON

Country: Canada

Postal Code: L5R4H1

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

26-JUN-14

5. Location of incident.

Country: UNITED STATES

Prov / State: UNKNOWN

6. Date incident was first observed.

24-JUN-14

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)

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PMRA Registration No. 30664      PMRA Submission No.       EPA Registration No. 241-392

Product Name: CHLORFENAPYR TECHNICAL INSECTICIDE

• Active Ingredient(s)
  • CHLORFENAPYR

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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).

PCO applied spot and crack and crevice treatments inside home

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

Bird / Oiseau

3. Breed

macaw parrot

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

12

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

• General
  • Symptom - Death

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?

Other / Autre

specify unknown, as 2 parrots were kept in an untreated room and inside a covered cage

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

unclear how any exposure occured, as 2 parrots kept in covered cage in untreated room-one parrot died later, volatility low, route of possible exposure questionable

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here

No clear exposure