Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-2396
2. Registrant Information.
Registrant Reference Number: 2010-12
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.
26-MAY-10
5. Location of incident.
Country: UNITED STATES
Prov / State: NORTH CAROLINA
6. Date incident was first observed.
26-MAY-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. 241-392
Product Name: Phantom Termiticide
PMRA Registration No.
PMRA Submission No.
EPA Registration No. 7969-210
Product Name: Termidor
7. b) Type of formulation.
Liquid
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
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).
Phantom was applied by PCO inside home and another termiticide product (not registered in Canada by BASF) was applied outside. PCO states products were diluted and applied as per label.
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Yes
Subform III: Domestic Animal Incident Report
1. Source of Report
Other
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 )
0.3
7. Weight (provide a range if necessary )
Unknown
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
12. How long did the symptoms last?
Persisted until death
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
Died
16. How was the animal exposed?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Indoor application of Phantom. PCO company called application of product occured as per label (PCO),owners were told to wait until product dried to let dog near.Pet also had vaccine.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
PCO applied Phantom termiticide at 1:43 {invoice time of application 2:43} inside residence,another termiticide outside. Dog was vaccinated yesterday. Owner informed PCO that dog had difficulty breathing and they were going to vet.Owner called back to say pet died;PCO believes this was at 4-4:30. Because time course was unk consistent, amt was unk consistent, and findings were unk consistent, this substance was considered to have unk likelihood of causing clinical situation.