Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2009-3782
2. Registrant Information.
Registrant Reference Number: 2009-IR-06
Registrant Name (Full Legal Name no abbreviations): E.I. du Pont Canada Company
Address: 7070 Mississauga Road
City: Mississauga
Prov / State: ON
Country: Canada
Postal Code: L5N 5M8
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
14-SEP-09
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
30-JUL-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. 27348
PMRA Submission No.
EPA Registration No.
Product Name: Kocide 2000
- Active Ingredient(s)
- COPPER AS ELEMENTAL (PRESENT AS COPPER HYDROXIDE)
PMRA Registration No.
PMRA Submission No.
EPA Registration No.
Product Name: Manzate
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: Agricultural-Outdoor/Agricole-extérieur
Préciser le type: unknown
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Product(s) were applied to a field adjacent to the property where the animal lived. Application method, use rates not known
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
Other
2. Type of animal affected
Dog / Chien
3. Breed
Great Dane
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
1.5
7. Weight (provide a range if necessary )
160
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>3 days <=1 wk / >3 jours <=1 sem
11. List all symptoms
System
- Nervous and Muscular Systems
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Unknown/Inconnu
16. How was the animal exposed?
Other / Autre
specify method of exposure unknown - may have been spray drift or overspray of dog's yard.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Incident occurred in (location) and local veterinarian contacted (name) Poison and Drug Centre, (city, state) (case # ). Field adjacent to dog yard was sprayed on July 29, Aug 19 and Aug 25. Dog had moderate seizures on July 30, Aug 20 and Aug 30. "Because the time course was not consistent , the amount was unknown consistent, and the findings were not consistent, this substance was considered to have not related liklihood of causing the clinical situation". Epilepsy was considered to have "medium liklihood of causing the clinical situation." Symptomatic treatment was recommended.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here