Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-2912
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.
29-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. 29778
PMRA Submission No.
EPA Registration No.
Product Name: K9 ADVANTIX II MEDIUM DOG
- Active Ingredient(s)
- IMIDACLOPRID
- PERMETHRIN
- 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: Between shoulder blades
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Owner placed 1 tube contents on skin between shoulder blades.
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
Shin Tzu
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
7.3
7. Weight (provide a range if necessary )
4.5
kg
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Skin
- Symptom - Irritated skin
- Symptom - Red skin
12. How long did the symptoms last?
>2 hrs <=8 hrs / > 2 h < = 8 h
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?
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
Used for flea/tick prevention. Owner placed 1 tubes contents on skin between shoulder blades within a few hours developed severe irritation + itch - vocalizing, rubbing, trying to scratch. Owner washed area which improved, but still tried to rub - skin red/irritated - applied vitamin E owner brought dog to clinic for recheck 1 week later - we gave vanedyl-p ((1/2 tab BID for 3 days, then 1/2 tab SID for 3 days, 1/2 tab q other day until finished). Overall state of health at the time of reaction is good.Date used product on 2017-05-29.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Not Applicable
19. Provide supplemental information here