Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-7309
2. Registrant Information.
Registrant Reference Number: ProPharma Group case #: 1-50383091
Registrant Name (Full Legal Name no abbreviations): Syngenta Canada Inc.
Address: 140 Research Lane, Research Park
City: Guelph
Prov / State: Ontario
Country: Canada
Postal Code: N1G4Z3
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
11-NOV-17
5. Location of incident.
Country: UNITED STATES
Prov / State: FLORIDA
6. Date incident was first observed.
05-NOV-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. 100-1066
Product Name: DEMAND CS INSECTICIDE
- Active Ingredient(s)
- LAMBDA-CYHALOTHRIN
- Guarantee/concentration 9.7 %
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. - Out Home / Rés - à l'ext.maison
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
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
Rottweiler
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
6.5
7. Weight (provide a range if necessary )
70
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
12. How long did the symptoms last?
Persisted until death
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
Died
16. How was the animal exposed?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1-50383091 - The reporter, a pet owner, indicates an exposure to a pesticide containing the active ingredient lambda-cyhalothrin. The reporter indicates his 6.5-year-old, 70-pound, female, Rottweiler dog had access to a treated area an unknown amount of time after application. An actual exposure was not witnessed. The reporter stated the dog died suddenly six days before the day of initial contact with the registrant. The reporter was advised this would not be an expected reaction to normal product use. No additional information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here