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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2002

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): Wildlife Biologist, investigating poisoining incident

Address: x

City: x

Prov / State: x

Country: x

Postal Code: X

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

Domestic Animal

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA


6. Date incident was first observed.


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.


PMRA Registration No.       PMRA Submission No.       EPA Registration No.

Product Name:

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


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

Site: Unknown / Inconnu

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

Suspect intentional bait, given location/time of year

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?


Subform III: Domestic Animal Incident Report

1. Source of Report


2. Type of animal affected

Dog / Chien

3. Breed

blue heeler x border collie

4. Number of animals affected


5. Sex


6. Age (provide a range if necessary )


7. Weight (provide a range if necessary )


8. Route(s) of exposure


9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms


  • General
    • Symptom - Death
  • Gastrointestinal System
    • Symptom - Vomiting
  • Blood
    • Symptom - Bleeding
    • Specify - Blood coming from nose

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.


14. a) Was the animal hospitalized?


14. b) How long was the animal hospitalized?

15. Outcome of the incident


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

Dog vomited outside in a couple of different locations, brought into residence, dog died within 45 minutes, dog was put back outside and 10 minutes later owner observed blood coming from it's nose. Suspected inadvertently [exposure].Stomach contents of dog analyzed for suite of OP/Carbamate pesticides. Detected: Carbofuran 507 ppm; carbofuran 3-OH 1.53 ppm; bendiocarb 33 ppm; aldicarb 3.61 ppm; aldicarb sulfoxide 0.18 ppm; disulfoton 1.62 ppm BC Wild Bird Mortality Investigation # Investigated in conjunction with two magpie found dead in the same area on 6-Feb-11. The residents new puppy had eaten one of the magpie (feathers found in dog house) & was subsequently sick (though recovered). BCMAL AHL examined intact magpie - diagnosis: not specified (brain cholinsterase within normal level for species, 21.9 umol/min/g, so pesticides not suspected).

To be determined by Registrant

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

Not Applicable

19. Provide supplemental information here