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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2009-0006
2. Registrant Information.
Registrant Reference Number: Prosar case 1-16217959
Registrant Name (Full Legal Name no abbreviations): United Agri Products Canada, Inc.
Address: 789 Donnybrook Drive
City: Dorchester
Prov / State: Ontario
Country: Canada
Postal Code: N0L1G5
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
01-JUN-085. Location of incident.
Country: CANADA
Prov / State: ALBERTA
6. Date incident was first observed.
31-MAY-08Product 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. 27884 PMRA Submission No. EPA Registration No.
Product Name: Par III Turf Herbicide
- Active Ingredient(s)
- 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)
- DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, OR SODIUM SALT)
- MECOPROP P-ISOMER PRESENT AS DIMETHYLAMINE SALT
7. b) Type of formulation.
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).
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
Medical Professional
2. Type of animal affected
Dog / Chien
3. Breed
Bichon Frise
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
15
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 - Vomiting
- Symptom - Diarrhea
- Symptom - Anorexia
- General
- Symptom - Lethargy
12. How long did the symptoms last?
>24 hrs <=3 days / >24 h <=3 jours
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
Fully Recovered / Complètement rétabli
16. How was the animal exposed?
Other / Autre
specify No witnessed exposure. Animal owner thought the dog may have licked product off his paws.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1-16217959: The reporter, a veterinarian, called on 6/1/08 to report the use of a product containing the active ingredients Dicamba, Mecoprop-p, and 2,4,D the previous day. According to the reporter, the owner of a Bichon Frise had sprayed the yard 5/31/08, and the dog had been in the yard all day. The owner thought the dog may have ingested product by licking his paws. The evening of 5/31, the dog had developed vomiting, diarrhea, anorexia, and lethargy. The safety profile of the product was discussed. Symptomatic and supportive care was advised. A follow-up call was placed. When the reporter called back (6/12), it was revealed that the dog had been diagnosed with gastric irritation. The dog's symptoms had resolved after several days. Pepto Bismol had been given as part of the treatment.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
