Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-1185
2. Registrant Information.
Registrant Reference Number: 628085
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.
05-MAY-10
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
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. 27566
PMRA Submission No.
EPA Registration No.
Product Name: RAXIL T (Canada)
7. b) Type of formulation.
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
Horse / Cheval
3. Breed
Mixed Breed (Grade)
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
22
7. Weight (provide a range if necessary )
880.00
lbs
8. Route(s) of exposure
Oral
9. What was the length of exposure?
>1 wk <=1 mo / > 1 sem < = 1 mois
10. Time between exposure and onset of symptoms
>1 wk <=1 mo / > 1 sem < = 1 mois
11. List all symptoms
System
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
No
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Unknown/Inconnu
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
5/5/2010 Caller reports that they have been accidentally giving this product to the horse instead of feed for the past month. The horse has been given about 25 pounds of the product over this time. The horse has lost between 30 and 40 pounds.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
19. Provide supplemental information here