Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2008-3081
2. Registrant Information.
Registrant Reference Number: 318897
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.
13-MAY-08
5. Location of incident.
Country: UNITED STATES
Prov / State: NORTH CAROLINA
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. 72155-58
Product Name: Carpenter Ant + Termite Killer Plus Concentrate
- Active Ingredient(s)
- CYFLUTHRIN
- Guarantee/concentration 2.5 %
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
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
Domestic short hair
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
10
7. Weight (provide a range if necessary )
10
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Other
- Specify - Blood in mouth of unknown origin. Unclear if from stomach or oral cavity.
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
No
14. a) Was the animal hospitalized?
No
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
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
5/13/2008 Caller reports applying diluted product to an area on the ground in front of a door two weeks ago. Caller's cat was found dead outside with blood in the mouth one week later. The cat did not have any known exposure to the product but was had been allowed free access to the area where the pesticide was applied. The cat was never evaluated by a veterinarian.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here