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: 2011-2409

2. Registrant Information.

Registrant Reference Number: 2011-16

Registrant Name (Full Legal Name no abbreviations): BASF Canada

Address: 100 Milverton, 5th floor

City: Mississauga

Prov / State: ON

Country: Canada

Postal Code: L5R4H1

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

Domestic Animal

4. Date registrant was first informed of the incident.

13-JUN-11

5. Location of incident.

Country: UNITED STATES

Prov / State: ALABAMA

6. Date incident was first observed.

09-JUN-11

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. 2010-0613      EPA Registration No. 241-392

Product Name: Phantom

  • Active Ingredient(s)
    • CHLORFENAPYR

7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Yes

9. Application Rate.

.75

Other Units: oz/gallon

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).

Phantom applied outside home by PCO. Product was diluted to 0.75 oz/gal

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

Parson Russel terrier

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

5

7. Weight (provide a range if necessary )

25

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

>2 hrs <=8 hrs / >2 h <=8 h

10. Time between exposure and onset of symptoms

>30 min <=2 hrs / >30 min <=2 h

11. List all symptoms

System

  • Nervous and Muscular Systems
    • Symptom - Recumbent
  • General
    • Symptom - Hyperthermia
    • Symptom - Death

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?

Unknown

15. Outcome of the incident

Died

16. How was the animal exposed?

Other / Autre

specify unknown, animal was in yard while dilute material applied

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

Diluted material applied to outside house, animal was in yard. Two hours after premises treated, owner found dog lying in yard, she took dog to the clinic and dog passed away there. Dog had an elevated body temperature; it was also a very hot day. DVM mentioned heat stroke or toxicity. Caller does not think that the product would have formed puddles.


To be determined by Registrant

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

Death

19. Provide supplemental information here

Unknown likelihood