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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2008-1177
2. Registrant Information.
Registrant Reference Number: 2008-02-12-a
Registrant Name (Full Legal Name no abbreviations): Certified Lab Products, Div. of NCH Canada Inc.
Address: 239 Orenda Road
City: Brampton
Prov / State: Ontario
Country: Canada
Postal Code: L6T 1E6
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
12-FEB-08
5. Location of incident.
Country: CANADA
Prov / State: ALBERTA
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. 24402
PMRA Submission No.
EPA Registration No.
Product Name: Verm-Chek
7. b) Type of formulation.
Application Information
8. Product was applied?
No
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
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
German Shepherd
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
Oral
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?
Unknown / Inconnu
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?
Accidental ingestion/Ingestion accident.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
The owner reports that the lid was left off the container that held the pesticide. The container was in an area accessible to the dog. The dog ingested pesticide from the opened container. Result was death of the dog.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here