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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2014-4174
2. Registrant Information.
Registrant Reference Number: 1448574
Registrant Name (Full Legal Name no abbreviations): Bayer CropScience Inc.
Address: 295 Henderson Drive
City: Regina
Prov / State: SK
Country: Canada
Postal Code: S4N 6C2
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
21-AUG-145. Location of incident.
Country: CANADA
Prov / State: NEW BRUNSWICK
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. 28791 PMRA Submission No. EPA Registration No.
Product Name: DELTAGARD SC INSECTICIDE (CANADA)
- Active Ingredient(s)
- DELTAMETHRIN
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. - Out Home / Rés - à l'ext.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?
YesSubform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Border Collie
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
5
7. Weight (provide a range if necessary )
34.00
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>1 wk <=1 mo / > 1 sem < = 1 mois
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Diarrhea
- Symptom - Vomiting
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
Unknown
15. Outcome of the incident
Unknown/Inconnu
16. How was the animal exposed?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
8/21/2014 Caller reports that the product was sprayed in her yard on 8/5/2014. Caller's dogs had been let out into the treated areas several times without issue. Caller states that one dog developed vomiting and diarrhea on 8/14/2014. Caller states that another dog developed vomiting and diarrhea after the first dog, but also developed seizures yesterday and died while being treated by their veterinarian. The first dog is still being treated with intravenous fluids, anti-emetics and antibiotics. Caller stated that the veterinarian thinks that the symptoms were caused by some type of toxin. The veterinarian recommended that caller check around her home and property for any products which may be of concern. The veterinarian suspected some type of rat poison, and also did not think the time frame seemed right for an insecticide to cause the symptoms. 8/29/2014 Attempted call back to the original caller. A message was left requesting follow up information. 9/8/2014 Attempted call back to the original caller. A message was left requesting follow up information.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
19. Provide supplemental information here
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Australian Shepherd (Aussie)
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
7
7. Weight (provide a range if necessary )
54.00
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>1 wk <=1 mo / > 1 sem < = 1 mois
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Diarrhea
- Symptom - Vomiting
- General
- Symptom - Death
- Nervous and Muscular Systems
- Symptom - Seizure
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
Yes
14. b) How long was the animal hospitalized?
Unknown
15. Outcome of the incident
Died
16. How was the animal exposed?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
8/21/2014 Caller reports that the product was sprayed in her yard on 8/5/2014. Caller's dogs had been let out into the treated areas several times without issue. Caller states that one dog developed vomiting and diarrhea on 8/14/2014. Caller states that another dog developed vomiting and diarrhea after the first dog, but also developed seizures yesterday and died while being treated by their veterinarian. The first dog is still being treated with intravenous fluids, anti-emetics and antibiotics. Caller stated that the veterinarian thinks that the symptoms were caused by some type of toxin. The veterinarian recommended that caller check around her home and property for any products which may be of concern. The veterinarian suspected some type of rat poison, and also did not think the time frame seemed right for an insecticide to cause the symptoms. 8/29/2014 Attempted call back to the original caller. A message was left requesting follow up information. 9/8/2014 Attempted call back to the original caller. A message was left requesting follow up information.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
