Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2007-8645
2. Registrant Information.
Registrant Reference Number: 210530
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.
12-JUL-07
5. Location of incident.
Country: UNITED STATES
Prov / State: WYOMING
6. Date incident was first observed.
09-JUL-07
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. 72155-55
Product Name: Tree + Shrub Insect Control (1 gal)72155-55
- Active Ingredient(s)
- IMIDACLOPRID
- Guarantee/concentration 1.47 %
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).
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
Medical Professional
2. Type of animal affected
Dog / Chien
3. Breed
German Shepherd
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
0.16
7. Weight (provide a range if necessary )
12.00
lbs
8. Route(s) of exposure
Oral
9. What was the length of exposure?
<=15 min / <=15 min
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Vomiting
- Symptom - Diarrhea
- Symptom -
- Specify - Megaesophagus
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?
Yes
14. b) How long was the animal hospitalized?
2
Day(s) / Jour(s)
15. Outcome of the incident
Euthanised / Euthanasie
16. How was the animal exposed?
Other / Autre
specify Defined point of exposure not evident or witnessed. Exposure based on speculation.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
7/12/2007DVM called to report a dog who presents with a history of vomiting and diarrhea for the previous 3 days. The pesticide had been applied around the property at an unspecified period of time. The owners suspect the dog may have had some kind of contact with plants treated with this pesticide.Follow-up on 7/26/2007Follow-up with treating DVM. The dog ended up being euthanized due to megaesophagus. DVM verified that this was completely unrelated to the pesticide.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here