Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2004

2. Registrant Information.

Registrant Reference Number: PROSAR Case 1-25944566

Registrant Name (Full Legal Name no abbreviations): 14111 Scottslawn Road

Address: 2000 Argentia Road, Plaza 5, Suite 101

City: Marysville

Prov / State: Ohio

Country: USA

Postal Code: 43041

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

Domestic Animal

4. Date registrant was first informed of the incident.

22-APR-11

5. Location of incident.

Country: UNITED STATES

Prov / State: FLORIDA

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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 2217-910-239

Product Name: Weed-B-Gon Max for Southern Lawns Concentrate

• Active Ingredient(s)
  • 2,4-D (PRESENT AS LOW VOLATILE ESTERS)
    • Guarantee/concentration 4.01 %
  • CARFENTRAZONE-ETHYL
  • DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, OR SODIUM SALT)
    • Guarantee/concentration .27 %
  • MECOPROP P-ISOMER (PRESENT AS ACID)
    • Guarantee/concentration .49 %

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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).

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

Other

2. Type of animal affected

Dog / Chien

3. Breed

unknown

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

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

• General
  • Symptom - Death

12. How long did the symptoms last?

Persisted until death

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

Unknown

14. a) Was the animal hospitalized?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

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

1-25944566- The reporter indicates his neighbor s animal may have been exposed to an herbicide containing the active ingredients 2,4-Dichlorophenoxyacetic acid (isooctyl (2-ethylhexyl) ester), Mecoprop-P, Dicamba, and Carfentrazone. The reporter indicated his neighbor s dog (nonspecific) had died a couple weeks after applying. The caller did not offer when the product was used, signalment of the dog, any signs that might have preceded the animal¿s death, or if the animal had seen the veterinarian prior to its death. The caller did not describe a discreet exposure incident. The caller did indicate he did not believe the animal s death was associated with the product and further added that he believed his neighbor is merely trying to blame him for the animal s death. The outcome seen would not be expected following use of the product as labeled. Exposure to wet product applied as labeled may irritate body surfaces exposed.

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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