Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-3366

2. Registrant Information.

Registrant Reference Number: 2011-IR-06

Registrant Name (Full Legal Name no abbreviations): E.I. du Pont Canada Company

Address: 7070 Mississauga Road

City: Mississauga

Prov / State: ON

Country: Canada

Postal Code: LN 5M8

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

Domestic Animal

4. Date registrant was first informed of the incident.

02-AUG-11

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

6. Date incident was first observed.

02-JUL-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)

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PMRA Registration No. 14417      PMRA Submission No.       EPA Registration No.

Product Name: Kocide 101Fungicide

• Active Ingredient(s)
  • COPPER AS ELEMENTAL (PRESENT AS COPPER HYDROXIDE)

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7. b) Type of formulation.

Application Information

8. Product was applied?

No

9. Application Rate.

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

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

mixed breed

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

6

7. Weight (provide a range if necessary )

80

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

<=15 min / <=15 min

10. Time between exposure and onset of symptoms

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

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Vomiting

12. How long did the symptoms last?

Unknown / Inconnu

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

Unknown/Inconnu

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 got into a bag of Kocide 101and a short time afterwards began vomiting. the owner didn't think she ate much of it. no other products were involved. the dog is generally healthy. It is considered an acute canine ingestion of fungicide.

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To be determined by Registrant

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

Minor

19. Provide supplemental information here

Owner called poison control. poison control referred to MSDS and advised owner to: wash muzzle and paws, offer fresh water to drink. Since the dog was symptomatic, they should contact their vet for treatment and to call back with any further concerns.