Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2009-3477
2. Registrant Information.
Registrant Reference Number: Prosar 1-19693429
Registrant Name (Full Legal Name no abbreviations): Matson, LLC
Address: 45620 S. E. 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.
31-AUG-09
5. Location of incident.
Country: UNITED STATES
Prov / State: CALIFORNIA
6. Date incident was first observed.
31-AUG-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. 8119-13
Product Name: Corrys Slug/Snail Pellets MP 4 lb
- Active Ingredient(s)
- METALDEHYDE
- Guarantee/concentration 3.25 %
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
Siberian Husky
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
5
7. Weight (provide a range if necessary )
Unknown
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
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
1-19693429: A reporter (dog owner) called on 08/31/2009 to report her dog's exposure to a snail and slug bait containing the active ingredient Metaldehyde. According to the reporter, the dog ingested an unknown amount of product and was panting and seizing at the time of the report. The reporter was advised that the dog should be seen immediately by a veterinarian for evaluation and treatment. On follow up, the reporter stated that the dog died 10 minutes after the report was made, before the reporter could get her to a veterinarian. 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