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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-3095

2. Registrant Information.

Registrant Reference Number: 10061301

Registrant Name (Full Legal Name no abbreviations): Nufarm Agriculture Inc

Address: 5507 1st St SE

City: Calgary

Prov / State: Alberta

Country: Canada

Postal Code: T2H 1H9

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

Domestic Animal

4. Date registrant was first informed of the incident.

13-JUN-10

5. Location of incident.

Country: UNITED STATES

Prov / State: PENNSYLVANIA

6. Date incident was first observed.

13-JUN-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.       EPA Registration No.

Product Name: Unknown

  • Active Ingredient(s)
    • GLYPHOSATE
      • Unknown

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. - Out Home / Rés - à l'ext.maison

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

Product was applied 4 days ago in yard. He stated it was a round up like product. Caller stated he sprayed it and then left and unsure if dog was in area of yard.

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

Unknown

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

8

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Oral

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

  • Gastrointestinal System
    • Symptom - Diarrhea
    • Symptom - Anorexia
  • General
    • Symptom - Cancer
    • Specify - stomach
    • Symptom - Cancer
    • Specify - spleen
    • Symptom - Cancer
    • Specify - colon

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?

Unknown

15. Outcome of the incident

Euthanised / Euthanasie

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

Unknown weed killer sprayed 4 days ago in yard. Caller not near container and can't provide specific name of product. Caller stated next day dog developed diarrhea and not eating which has persisted. Advised it would be difficult to provide information with no product information. Told to have dog evaluated by DVM, maintain hydration. On call back DVM diagnosed dog with cancer in the stomach, spleen and colon. DVM did not feel that the weed killer had anything to do with the diagnosis. Elected to have the dog euthanized.


To be determined by Registrant

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

Death

19. Provide supplemental information here