Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2007-6058
2. Registrant Information.
Registrant Reference Number: 182934
Registrant Name (Full Legal Name no abbreviations): Bayer CropScience Inc.
Address: Suite 100, 3131 114 Avenue SE
City: Calgary
Prov / State: AB
Country: Canada
Postal Code: T2Z 3X2
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
03-MAY-07
5. Location of incident.
Country: UNITED STATES
Prov / State: FLORIDA
6. Date incident was first observed.
Unknown
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.
Product Name: Suspend SC
- Active Ingredient(s)
- DELTAMETHRIN
- Guarantee/concentration 4.75 %
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).
Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding application.
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
Other
2. Type of animal affected
Dog / Chien
3. Breed
Unknown
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- Nervous and Muscular Systems
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
Not recovered / Non rétabli
16. How was the animal exposed?
Other / Autre
specify There was no known or witnessed exposure to pesticide.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
5/3/2007PCO called to report that an owner of a dog died an unspecified period of time after product was applied in home via a crack and crevice application with diluted pesticide. The dog reportedly developed a seizure disorder the day following application, but is not known how the dog would have been exposed to pesticide since it was applied to cracks and crevices. No exposure was actually witnessed or observed by the dog owner. No information on the dog is available or how the dog was treated.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here