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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2832

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-26444057

Registrant Name (Full Legal Name no abbreviations): Matson, LLC

Address: 45620 S. E. North Bend Way ¿ P.O. Box 1820

City: North Bend

Prov / State: Washington

Country: USA

Postal Code: 98045

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

Domestic Animal

4. Date registrant was first informed of the incident.

09-JUN-11

5. Location of incident.

Country: UNITED STATES

Prov / State: UTAH

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.       EPA Registration No. 8119-13

Product Name: Corrys Slug Snail Pellets MP

  • Active Ingredient(s)
    • METALDEHYDE
      • Guarantee/concentration 3.25 %

7. b) Type of formulation.

Bait

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

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Miniature Dachshund

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

7

7. Weight (provide a range if necessary )

11

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

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 - Fasciculations
  • General
    • Symptom - Adipsia
    • Specify - would not drink
    • Symptom - Other
    • Specify - will not sit or lay down
  • Nervous and Muscular Systems
    • Symptom - Seizure
  • Cardiovascular System
    • Symptom - Cardiac arrest
  • Respiratory System
    • Symptom - Respiratory failure

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?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

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

1-26444057- the reporter, a pet owner, indicates her animal was exposed to a pesticide containing the active ingredient metaldehyde. The pet owner indicates his seven year female eleven pound miniature dachshund dog had been at his mother¿ home ninety minutes preceding the call. The pet owner indicated the animal had ingested an unknown amount of the product that had been applied to the lawn. The animal was reported to have developed tremor within one hour of ingestion. The animal would not drink and refused to sit. The caller was advised to seek immediate veterinary care. They were informed of the standards of care and prognosis. On follow up the pet owner indicated the animal had seizures on the way to the veterinarian and had died at the veterinary office. The caller indicated the cause of death was cardiac and respiratory arrest/failure. No further information is available.


To be determined by Registrant

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

Death

19. Provide supplemental information here