Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2009-1950
2. Registrant Information.
Registrant Reference Number: Prosar 1-18527777
Registrant Name (Full Legal Name no abbreviations): Matson, LLC
Address: 45620 North Bend Way-P.O. Box 1820
City: North Bend
Prov / State: Washington
Country: USA
Postal Code: 98045
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
19-MAY-09
5. Location of incident.
Country: UNITED STATES
Prov / State: CALIFORNIA
6. Date incident was first observed.
19-MAY-09
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.
Product Name: Unknown Metaldehyde-based Slug and Snail Killer
7. b) Type of formulation.
Bait
Application Information
8. Product was applied?
Unknown
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?
Unknown
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
German Shorthair Pointer
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
50
lbs
8. Route(s) of exposure
Oral
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Nervous and Muscular Systems
- Symptom - Shaking
- Symptom - Seizure
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?
Accidental ingestion/Ingestion accident.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1-18527777: A reporter (dog owner) called on 05/19/2009 to report the exposure of his dog to a slug and snail bait containing the active ingredient Metaldehyde. According to the reporter, the dog ate some of the product at an unknown time and was shaking at the time of the report. The reporter was advised that the product is highly toxic in small amounts and acts quickly so the dog must be seen by a veterinarian immediately. The reporter was also advised that ingestion of the product may result in muscle tremors, hyperthermia, and decreased respiratory effort. The dog should be decontaminated by the veterinarian. On follow up, the reporter stated that he was unable to get the dog to a veterinarian. It started having seizures and died at home on 05/19/2009. No further information was obtained.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here