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Consumer Product Safety

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

  • Active Ingredient(s)
    • CHLORFENAPYR

PMRA Registration No.       PMRA Submission No.       EPA Registration No. 7969-210

Product Name: Termidor

  • Active Ingredient(s)
    • FIPRONIL

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

  • Respiratory System
    • Symptom - Dyspnea
  • General
    • Symptom - Death

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.