Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-2962
2. Registrant Information.
Registrant Reference Number: PROSAR case #: 1-40954468
Registrant Name (Full Legal Name no abbreviations): Syngenta Canada Inc.
Address: 140 Research Lane, Research Park
City: Guelph
Prov / State: Ontario
Country: Canada
Postal Code: N1G4Z3
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
18-JUN-15
5. Location of incident.
Country: UNITED STATES
Prov / State: SOUTH CAROLINA
6. Date incident was first observed.
16-JUN-15
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. 100-1260
Product Name: Optigard Ant Gel Bait
- Active Ingredient(s)
- THIAMETHOXAM
- Guarantee/concentration .01 %
7. b) Type of formulation.
Bait
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).
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
Scottish Terrier
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
12
7. Weight (provide a range if necessary )
19
lbs
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
- Gastrointestinal System
- Symptom - Vomiting
- Symptom - Diarrhea
- General
- Symptom - Fever
- Symptom - Death
- Liver
- Symptom - Enlargement of the liver
- Symptom - Elevated liver enzymes
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?
1
Day(s) / Jour(s)
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
1-40954468 - The reporter, a pet owner, indicated that her dog may have been exposed to an insecticide containing the active ingredient thiamethoxam. The reporter stated that a PCO applied this product in her home no exposure to the product was witnessed but two days prior to initial contact with the registrant she woke up and found her 12-year-old, 19 pound, female Scottish terrier in the bathroom with evidence of vomiting and diarrhea in the home. The dog was brought to the ER clinic that morning where it was found to have a fever of 106F, slight elevations in liver enzymes and an enlarged liver was seen on radiographs. The dog was started on IV fluids and antibiotics but died later that evening. At the time of death the veterinarian recommended a necropsy but it was declined. The reporter was advised that the described symptoms are not consistent with exposure to this product. No additional information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here