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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-1814

2. Registrant Information.

Registrant Reference Number: 26620

Registrant Name (Full Legal Name no abbreviations): V¿toquinol N.-A. Inc.

Address: 2000 ch. Georges

City: Lavaltrie

Prov / State: QC

Country: Canada

Postal Code: J5T 3S5

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.


5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.


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.


PMRA Registration No. 26620      PMRA Submission No.       EPA Registration No.

Product Name: Active 3

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


Units: mL

10. Site pesticide was applied to (select all that apply).

Site: Animal / Usage sur un animal domestique

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Application topique sur la peau du chien des deux ampoules de 1,5 mL

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?


Subform III: Domestic Animal Incident Report

1. Source of Report

Medical Professional

2. Type of animal affected

Dog / Chien

3. Breed


4. Number of animals affected


5. Sex


6. Age (provide a range if necessary )


7. Weight (provide a range if necessary )



8. Route(s) of exposure


9. What was the length of exposure?

>1 wk <=1 mo / > 1 sem < = 1 mois

10. Time between exposure and onset of symptoms

>30 min <=2 hrs / >30 min <=2 h

11. List all symptoms


  • Skin
    • Symptom - Itchy skin
    • Symptom - Dermatitis

12. How long did the symptoms last?

>1 wk <=1 mo / > 1 sem < = 1 mois

13. Was medical treatment provided? Provide details in question 17.


14. a) Was the animal hospitalized?


14. b) How long was the animal hospitalized?

15. Outcome of the incident

Fully Recovered / Complètement rétabli

16. How was the animal exposed?

Treatment / Traitement

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

Intense prurit dans les heures suivants l'applications puis d¿veloppement d'une pyodermite bact¿rienne secondaire dans les semaines suivantes (prurit, mordillage, l¿chage excessif, cro¿tes)

To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification


19. Provide supplemental information here

R¿action de sensibilit¿ cutan¿e d¿crite dans la section "R¿actions ind¿sirables" de l'emballage. Si l'animal avait ¿t¿ baign¿/soigneusement lav¿ d¿s l'apparition des premi¿res manifestations pruritiques, la pyodermite secondaire ne serait probablement pas apparue.