Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-6722
2. Registrant Information.
Registrant Reference Number: 2017-26
Registrant Name (Full Legal Name no abbreviations): BASF Canada
Address: 100 Milverton
City: Mississauga
Prov / State: ON
Country: Canada
Postal Code: L5R4H1
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
27-OCT-17
5. Location of incident.
Country: UNITED STATES
Prov / State: NEVADA
6. Date incident was first observed.
09-OCT-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. 241-392
Product Name: Phantom
PMRA Registration No.
PMRA Submission No.
EPA Registration No. 279-3081
Product Name: cynoff (FMC product)
- Active Ingredient(s)
- CYPERMETHRIN
- Guarantee/concentration 24.8 %
7. b) Type of formulation.
Liquid
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Res. - In Home / Rés. - à l'int. maison
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Products sprayed on or near guinea pig-believed deliberate, that is why (name) police officer call it in. May not be actually reportable, as deliberate misuse.
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
No
Subform III: Domestic Animal Incident Report
1. Source of Report
Other
2. Type of animal affected
Other / Autre
specify guinea pig
3. Breed
unk
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
0.5
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Skin
Oral
9. What was the length of exposure?
<=15 min / <=15 min
10. Time between exposure and onset of symptoms
<=30 min / <=30 min
11. List all symptoms
System
- Nervous and Muscular Systems
- Symptom - Seizure
- Symptom - Coma
- Eye
- Symptom - Other
- Specify - abnormal pupil shape
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
16. How was the animal exposed?
Intentional poison./Empois. intentionnel
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Seizures began immediately, taken to vet, animal put on oxygen but arrested and died. Exposure at noon, death by 2PM.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
Misuse of products, police report.