Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-3767
2. Registrant Information.
Registrant Reference Number: 2011CP077
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.
18-AUG-11
5. Location of incident.
Country: CANADA
Prov / State: QUEBEC
6. Date incident was first observed.
04-AUG-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:
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 dog's head , above the left eye
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
australian sheep dog
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
0.5
7. Weight (provide a range if necessary )
35
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
>1 wk <=1 mo / > 1 sem < = 1 mois
10. Time between exposure and onset of symptoms
>24 hrs <=3 days / >24 h <=3 jours
11. List all symptoms
System
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
No
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Unknown/Inconnu
16. How was the animal exposed?
Other / Autre
specify product was appplied to dog s head, above the left eye
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
dog was in a boarding kennel where the product was applied to the dog's head, above the left eye; owner picked up the dog 2 days later and noticed a white spot on the left eye; August 5 dog was examined and a conjunctivitis was noted; dog was treated with an eye ointment that contains a corticosteroid ;on August 17, the dog was reexamined and still had a severe conjunctivitis with a neo vascularization; veterinarain will consult an opthalmologist for treatment options
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
19. Provide supplemental information here
possible that some product ran in the dog's eye; dog was not examined until 3 days after the product was applied; product can be irritating to eye