Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-4486

2. Registrant Information.

Registrant Reference Number: PROSAR Case #1-27126840

Registrant Name (Full Legal Name no abbreviations): Syngenta Crop Protection Canada, Inc.

Address: 140 Research Lane, Research Park

City: Guelph

Prov / State: Ontario

Country: Canada

Postal Code: N1G4Z3

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

Domestic Animal

4. Date registrant was first informed of the incident.

12-AUG-11

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

Unknown

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. 17354      PMRA Submission No.       EPA Registration No.

Product Name: Ratak + Rodenticide Pellets

• Active Ingredient(s)
  • BRODIFACOUM

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Unknown / Inconnu

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?

No

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

unknown

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

2.5

7. Weight (provide a range if necessary )

39

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• Respiratory System
  • Symptom - Coughing

• General
  • Symptom - Lethargy

• Gastrointestinal System
  • Symptom - Anorexia

• Blood
  • Symptom - Anemia
  • Symptom - Cytopenia
  • Specify - low RBC count

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?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Fully Recovered / Complètement rétabli

16. How was the animal exposed?

Other / Autre

specify relay toxicity/chronic ingestion of pest killed by bait

17. Provide any additional details about the incident

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

1-27126840- The reporter, a pet owner indicated his animal was exposed to a rodenticide containing the active ingredient brodifacoum. The reporter indicated he had been using the product on his property to address a rodent problem. He was unable to describe how long the product had been used and did not describe placement of the product. The reporter indicated he had been burying dead rodents he presumed were killed by the product. He reports his two and one half year female thirty nine pound dog had been digging up those dead rodents and chronically ingesting them. The reporter indicated the animal had not been eating the bait directly. He stated three days prior to his initial contact with the registrant he had noted the dog coughing, lethargic and refusing food. The pet was brought to the veterinarian and it was noted the animal had a 'low RBC count'?. The veterinarian had done a blood test and detected the potential of rodenticide toxicity. The caller was unable to state what test the veterinarian had run. The pet was administered Vitamin K1 and had resumed normal behavior. The pet owner was advised that relay or secondary toxicity associated with this and similar active ingredients is rare but typically occurs when pets are allowed to chronically ingest rodents that have ingested the bait. Animals are typically at greater risk when rodents that have ingested the active ingredient make up a relatively large portion of the animals diet. More secure disposal of the rodent remains or restricting the dog's access would be recommended. No further information is available.

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To be determined by Registrant

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

Moderate

19. Provide supplemental information here