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Consumer Product Safety

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 - Itchy skin
  • General
    • Symptom - Vocalizing
  • 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