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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2369

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: xx

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.

18-MAY-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. 29535      PMRA Submission No.       EPA Registration No.

Product Name: Fiesta Broadleaf Herbicide and Fertilizer

  • Active Ingredient(s)
    • IRON (PRESENT AS FEHEDTA)

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

Préciser le type: lawn

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Caller reported that Weed Man attended her property on May 18 and sprayed the front lawn and backyard with environmentally friendly Fiesta Broadleaf Herbicide and Fertilizer. A sign was posted on the front yard.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Yes

Subform III: Domestic Animal Incident Report

1. Source of Report

Other

2. Type of animal affected

Dog / Chien

3. Breed

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

>8 hrs <=24 hrs / > 8 h < = 24 h

11. List all symptoms

System

  • General
    • Symptom - Death
  • Gastrointestinal System
    • Symptom - Vomiting
  • General
    • Symptom - Malaise
    • Specify - ill

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.

specify Exposure not described

17. Provide any additional details about the incident

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

Her dog was let out in the backyard later that day. When she returned from work her dog was very ill and was taken to the vet where the dog later died. Tests from the vet indicate that the dog was poisoned with ethylene glycol. The caller advised that tests on Fiesta could produce a false positive for ethylene glycol. Lab analysis from the vet were not provided to the Ministry for review. The Caller has requested the vet not cremate her dog yet in case there is a chance for further tests to be done to determine the cause of death. Caller has retained a sample of vomit from her dog for analysis.


To be determined by Registrant

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

Not Applicable

19. Provide supplemental information here