Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-7714

2. Registrant Information.

Registrant Reference Number: ProPharma Group case #: 1-46017889

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.

22-OCT-16

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

22-OCT-16

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. 21084      PMRA Submission No.       EPA Registration No.

Product Name: WEATHERBLOK XT BAIT CONTAINING RATAK RODENTICIDE

• Active Ingredient(s)
  • BRODIFACOUM

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7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

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

Maremma Sheepdog

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

5

7. Weight (provide a range if necessary )

75

lbs

8. Route(s) of exposure

Oral

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 - Anorexia

• General
  • Symptom - Lethargy

12. How long did the symptoms last?

Unknown / Inconnu

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

Unknown/Inconnu

16. How was the animal exposed?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

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

1-46017889 - The reporter, a pet owner, indicated his dog may have been exposed a pesticide with the active ingredient brodifacoum. One or two days before the day of initial contact with the registrant, the reporter indicated his 5-year-old, 75-pound, male, Maremma Sheepdog ingested an unknown amount of the product. On the day of initial contact, the reporter indicated the dog was lethargic and not eating. The reporter was advised to take the dog in to a veterinarian for evaluation and be placed on the antidote to the products active ingredient. On follow-up call two days later, the reporter indicated veterinary care had not been sought, but the dog felt a little better. The reporter was advised to get immediate medical attention for the dog. No additional information is available.

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To be determined by Registrant

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

Minor

19. Provide supplemental information here