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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-2315

2. Registrant Information.

Registrant Reference Number: 2010-11

Registrant Name (Full Legal Name no abbreviations): BASF Canada

Address: 100 Milverton, 5th floor

City: Mississauga

Prov / State: ON

Country: Canada

Postal Code: L5R4H1

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

23-APR-10

5. Location of incident.

Country: UNITED STATES

Prov / State: TEXAS

6. Date incident was first observed.

05-APR-10

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. 2010-0616      EPA Registration No.

Product Name: Phantom

  • Active Ingredient(s)
    • CHLORFENAPYR

7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Yes

9. Application Rate.

1

Units: oz (fl) / oz (liquide)

10. Site pesticide was applied to (select all that apply).

Site: Res. - In Home / Rés. - à l'int. maison

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Applied by PCO at 0.5oz/gallon x 2 gallons of diluted product in house

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

Shih Tzu

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

0.25

7. Weight (provide a range if necessary )

6

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

<=15 min / <=15 min

10. Time between exposure and onset of symptoms

>30 min <=2 hrs / >30 min <=2 h

11. List all symptoms

System

  • Gastrointestinal System
    • Symptom - Vomiting
  • Respiratory System
    • Symptom - Laboured breathing
  • Cardiovascular System
    • Symptom - Abnormally fast heart rate
  • Respiratory System
    • Symptom - Tachypnea
  • Cardiovascular System
    • Symptom - Tachycardia
  • General
    • Symptom - Death

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

Yes

14. a) Was the animal hospitalized?

Yes

14. b) How long was the animal hospitalized?

2

Hour(s) / Heure(s)

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

Dog licked from a small puddle off the floor. Animal was seen by vet, ASPCA provided information.DVM reported dog has rapid HR;fluids suggested at low rate for general support,DVM planned to put pup in some oxygen as well


To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here

PCO diluted product 0.5 oz per gallon of water and PCO used approx 2 gallons of dilute product in house. Because the time course was generally consistent, the amount was unknown consistent and the findings were somewhat consistent, low likelihood of causing the clinical situation.