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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-1898

2. Registrant Information.

Registrant Name (Full Legal Name no abbreviations): E. I. du Pont Canada Company

Address: P.O. box 2300, Streetsville

City: Mississauga

Prov / State: ON

Country: Canada

Postal Code: L5M 2J4

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: ONTARIO

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. 28286      PMRA Submission No.       EPA Registration No.

Product Name: Refine M

  • Active Ingredient(s)

PMRA Registration No. 27054      PMRA Submission No.       EPA Registration No.

Product Name: MCPA ester 500LV

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


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?


Subform III: Domestic Animal Incident Report

1. Source of Report

Medical Professional

2. Type of animal affected

Dog / Chien

3. Breed

lab retreiver

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?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms


  • Skin
    • Symptom - Jaundice
  • Renal System
    • Symptom - Blood in urine

12. How long did the symptoms last?

Unknown / Inconnu

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

Euthanised / Euthanasie

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

Owner brought dog into Vet clinic on May 13th. Thinks the dog may have ingested pesticide. Dog is very sick, jaundice, blood in urine. Started IV. They think a few days before that (possibly May 9th) dog may have ingested pesticide as a result of the overflow from a tank. Pesticide was mixed and used properly. Dog was not around when the overflow occured and Dog was not witnessed to have ingested the pesticide. The report indicates that the signs are not likely from the pesticide. Dog was euthanized.

To be determined by Registrant

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


19. Provide supplemental information here