Health Canada
Symbol of the Government of Canada
Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-3976

2. Registrant Information.

Registrant Reference Number: 641150

Registrant Name (Full Legal Name no abbreviations): Bayer CropScience Inc.

Address: #200, 160 Quarry Park Blvd SE

City: Calgary

Prov / State: AB

Country: Canada

Postal Code: T2C 3G3

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

Domestic Animal

4. Date registrant was first informed of the incident.

02-JUN-10

5. Location of incident.

Country: UNITED STATES

Prov / State: OKLAHOMA

6. Date incident was first observed.

Unknown

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. 72155-80

Product Name: Home Pest plus Germ Killer Indoor + Outdoor Killer RTU (1 Gal)

  • Active Ingredient(s)
    • CYFLUTHRIN
      • Guarantee/concentration .05 %
    • SODIUM O-PHENYLPHENATE
      • Guarantee/concentration .3 %

7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

No

9. Application Rate.

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

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

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

Mixed Breed

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

4

7. Weight (provide a range if necessary )

80.00

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

  • Cardiovascular System
    • Symptom - Arrhythmia
    • Symptom - Bradycardia
  • General
    • Symptom - Death
  • Nervous and Muscular Systems
    • Symptom - Rigidity
  • Respiratory System
    • Symptom - Cyanosis
    • Symptom - Nose bleed

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?

1

Day(s) / Jour(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

6/2/2010 Caller is a veterinarian treating a dog that presented with muscle rigidity, cyanosis, nose bleeding, and bradycardia. The dog was hooked up to an electrocardiogram, and no activity was detected. The dog was intubated and given epinephrine. The dog died during resuscitation attempts. The dog was alone in an open yard for six hours, and a gallon container of the product was found with bite marks in the bottle. The bottle was found empty but it is unknown if it had been empty prior to the dog having access to it. No necropsy was performed.


To be determined by Registrant

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

Death

19. Provide supplemental information here