Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-6298
2. Registrant Information.
Registrant Reference Number: 2017CK033
Registrant Name (Full Legal Name no abbreviations): Bayer Inc
Address: 2920 matheson BLVD
City: Mississaugua
Prov / State: ON
Country: Canada
Postal Code: L4W 5R6
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
31-MAY-17
5. Location of incident.
Country: CANADA
Prov / State: QUEBEC
6. Date incident was first observed.
24-APR-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. 29779
PMRA Submission No.
EPA Registration No.
Product Name: k9 advantix II extra large dog
- Active Ingredient(s)
- IMIDACLOPRID
- PERMETHRIN
- PYRIPROXYFEN
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
4
Units: mL
10. Site pesticide was applied to (select all that apply).
Site: Animal / Usage sur un animal domestique
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
On 23-Apr-2017, a 6 year old, 145 pound, neutered, male, Newfoundland canine, in unknown condition, with no known concomitant medical conditions, was administered 1 tube of K9 Advantix II Extra Large Dog (Imidacloprid-Permethrin-Pyriproxyfen) topically by the owner. The dog was secondarily environmental exposed to unspecified type of fungicide that was being sprayed on apple orchards on this date.
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Yes
Subform III: Domestic Animal Incident Report
1. Source of Report
Medical Professional
2. Type of animal affected
Dog / Chien
3. Breed
newfoundland
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
6
7. Weight (provide a range if necessary )
145
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
>1 wk <=1 mo / > 1 sem < = 1 mois
10. Time between exposure and onset of symptoms
>24 hrs <=3 days / >24 h <=3 jours
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Diarrhea
- Symptom - Anorexia
- Nervous and Muscular Systems
- Symptom - Bizarre behaviour
12. How long did the symptoms last?
>1 wk <=1 mo / > 1 sem < = 1 mois
13. Was medical treatment provided? Provide details in question 17.
No
14. a) Was the animal hospitalized?
No
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Fully Recovered / Complètement rétabli
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
On 24-Apr-2017 the dog was lethargic, had watery diarrhea, anorexia and was panting. On 25-Apr-2017 the dog was examined by the veterinarian. No treatment performed. On 26-Apr-2017 the diarrhea and anorexia resolved. On 29-Apr-2017 the lethargy and panting resolved. On approximately 01-May-2017 the dog developed a behavior disorder NOS (wouldn't go outside when spraying the fields). The dog was recovered within 2 weeks of developing the behavioural disorder
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here