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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-6568
2. Registrant Information.
Registrant Reference Number: 1666094
Registrant Name (Full Legal Name no abbreviations): Bayer CropScience Inc.
Address: 160 QUARRY PARK BLVD. SE Suite 200
City: CALGARY
Prov / State: AB
Country: Canada
Postal Code: T2C 3G3
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
13-AUG-155. Location of incident.
Country: UNITED STATES
Prov / State: NEW JERSEY
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. PMRA Submission No. EPA Registration No. 73049-185-72115
Product Name: Carpenter Ant and Termite Killer Plus - RTU
- Active Ingredient(s)
- DELTAMETHRIN
- Guarantee/concentration .02 %
- 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
Cat / Chat
3. Breed
DSH
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
1
7. Weight (provide a range if necessary )
8.00
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Eye
- Symptom - Pupil dilation
- General
- Symptom - Death
- Symptom - Lethargy
- Nervous and Muscular Systems
- Symptom - Difficulty getting up
- Symptom - Seizure
- Respiratory System
- Symptom - Shortness of breath
- Gastrointestinal System
- Symptom - Salivating excessively
- Specify - salivating
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?
No
14. b) How long was the animal hospitalized?
Unknown
15. Outcome of the incident
Died
16. How was the animal exposed?
Other / Autre
specify Defined point of exposure not evident or witnessed. Exposure based on speculation.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
8/13/2015 Caller is a veterinary technician at a clinic treating a cat that was found by the owner laying in the driveway with shallow breathing and appearing sedate and unresponsive. The cat has a fever of 103.3 degrees Fahrenheit, salivating, and head pressing. They have provided fluid therapy and obtained blood work. The only abnormality was total solids at 6.5. The owners treated the exterior of the home 4 days ago, and no direct exposure was witnessed. The cat may have also chewed up a citronella candle recently. 8/15/2015 Attempted call back to the original caller. A message was left requesting follow up information. 8/17/2015 Caller is returning the previous message. The cat seemed to be improving on 8/14/2015, but did appear blind with mydriasis. The cat was treated with subcutaneous fluids, Atropine, and force fed Nutri-Cal. The cat had what appeared to be a seizure on 8/15/2015, and died on 8/16/2015. She states that the pet was an outside cat exposed to an unknown toxin.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
