Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-0342

2. Registrant Information.

Registrant Reference Number: 2010-US-11023

Registrant Name (Full Legal Name no abbreviations): Intervet Canada Corp.

Address: 16750 Trancanada Highway

City: Kirkland

Prov / State: Quebec

Country: Canada

Postal Code: H9H 4M7

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

Domestic Animal

4. Date registrant was first informed of the incident.

11-NOV-10

5. Location of incident.

Country: UNITED STATES

Prov / State: MINNESOTA

6. Date incident was first observed.

11-NOV-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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 773-73

Product Name: Proticall

• Active Ingredient(s)
  • PERMETHRIN
    • Guarantee/concentration 65 %

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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

Animal's Owner

2. Type of animal affected

Cat / Chat

3. Breed

Siamese

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

0.5

7. Weight (provide a range if necessary )

4.5

lbs

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

• Nervous and Muscular Systems
  • Symptom - Ataxia
  • Symptom - Muscle tremors
  • Symptom - Convulsions

• General
  • Symptom - Hyperthermia

• Nervous and Muscular Systems
  • Symptom - Recumbent

12. How long did the symptoms last?

>8 hrs <=24 hrs / > 8 h < = 24 h

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

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

Cat became clinically ill with signs of recumbency, trembling, seizuring, tremors and hyperthermia on 11 Nov 10. The pet owners suspect that the cat had contact with insecticide through contact with the dog. Recommendations were given to treat the cat and included tremor and seizure control and supportive care. The vet reported that cat was euthanized on 11 Nov 2010 because of lack of response to treatment. Necropsy or other diagnostic testing was not performed.

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To be determined by Registrant

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

Death

19. Provide supplemental information here