Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-3331
2. Registrant Information.
Registrant Reference Number: 2011CP017
Registrant Name (Full Legal Name no abbreviations): Bayer Inc
Address: 77 Belfield Rd
City: Toronto
Prov / State: ON
Country: Canada
Postal Code: M9W 1G6
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
02-MAR-11
5. Location of incident.
Country: CANADA
Prov / State: QUEBEC
6. Date incident was first observed.
23-FEB-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. 27660
PMRA Submission No.
EPA Registration No.
Product Name: K9advantix55
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
2.5
Units: mL
10. Site pesticide was applied to (select all that apply).
Site: Animal / Usage sur un animal domestique
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
one tube was applied to the dorsal midline between the shoulder blades
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
No
Subform III: Domestic Animal Incident Report
1. Source of Report
Medical Professional
2. Type of animal affected
Dog / Chien
3. Breed
miniature schnauzer
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
5
7. Weight (provide a range if necessary )
21
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
>15 min <=2 hrs / >15 min <=2 h
10. Time between exposure and onset of symptoms
<=30 min / <=30 min
11. List all symptoms
System
- Nervous and Muscular Systems
- General
- Symptom - Abnormal behaviour
- Specify - rolling on back
12. How long did the symptoms last?
>30 min <=2 hrs / >30 min <=2 h
13. Was medical treatment provided? Provide details in question 17.
No
14. a) Was the animal hospitalized?
No
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Fully Recovered / Complètement rétabli
16. How was the animal exposed?
Treatment / Traitement
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
right after application, dog seemed agitated, started rolling on his back; owner gave the dog a bath immediately and the signs resolved
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here
Behavioural disorders may be a consequence of the uncomfortable feeling caused by the applied product. Considering the chronology sign probably related to paresthesia caused by permethrin ; dog was given an overdose; should have received K9advantix 20, which contains 1 ml