Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2008-3694
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.
08-JUL-08
5. Location of incident.
Country: CANADA
Prov / State: MANITOBA
6. Date incident was first observed.
01-JUN-08
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. 26620
PMRA Submission No.
EPA Registration No.
Product Name: Active 3
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
1.5
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 d'une ampoule de 1,5 ml
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
Bichon
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
10
7. Weight (provide a range if necessary )
16.4
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
>15 min <=2 hrs / >15 min <=2 h
10. Time between exposure and onset of symptoms
<=30 min / <=30 min
11. List all symptoms
System
- Skin
- Symptom - Red skin
- Symptom - Itchy skin
- Symptom - Lesion
- Specify - pyotraumatic lesion
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.
Yes
14. a) Was the animal hospitalized?
No
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
Rougeurs de la peau et prurit imm¿diatement apr¿s l'application puis d¿veloppement d'une l¿sion pyotraumatique au site d'application dans la semaine suivante
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
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 l¿sion pyotraumatique ne serait probablement pas apparue.