Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-2770
2. Registrant Information.
Registrant Reference Number: x
Registrant Name (Full Legal Name no abbreviations): x
Address: x
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.
01-MAY-17
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.
Product Name: Advantix II Medium
- Active Ingredient(s)
- IMIDACLOPRID
- PYRIPROXYFEN
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
1
Other Units: tube
10. Site pesticide was applied to (select all that apply).
Site: Animal / Usage sur un animal domestique
Préciser le type: on the dogs back on the skin
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Owner applied tube contents to the skin along the back
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
Shih trail poodle
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
14.2
7. Weight (provide a range if necessary )
5.9
kg
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>3 days <=1 wk / >3 jours <=1 sem
11. List all symptoms
System
- Nervous and Muscular Systems
- General
- Symptom - Vocalizing
- Specify - whimpering
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?
Treatment / Traitement
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Owner applied contents to the dogs back on the skin - no sign of discomfort that day. Next day seemed off - would not greet her at the door the next day whimpering . Was lethargic, shaking, whimpering for 2-3 days after application. We returned the product + changed to another preventative used to prevent flea and ticks.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Not Applicable
19. Provide supplemental information here