Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-5823
2. Registrant Information.
Registrant Reference Number: 110099269
Registrant Name (Full Legal Name no abbreviations): Dow AgroSciences Canada Inc.
Address: Suite 2100, 450 - 1st Street S.W.
City: Calgary
Prov / State: Alberta
Country: Canada
Postal Code: T2P 5H1
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: UNITED STATES
Prov / State: FLORIDA
6. Date incident was first observed.
02-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.
PMRA Submission No.
EPA Registration No. 62719-4
Product Name: Vikane Gas Fumigant
- Active Ingredient(s)
- SULFURYL FLUORIDE
- Guarantee/concentration 99
7. b) Type of formulation.
Other (specify)
Gas
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Res. - In Home / Rés. - à l'int. maison
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
The house was tented on 7/29 and exposure occurred at animal owner's home.
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
Medical Professional
2. Type of animal affected
Other / Autre
specify Gecko
3. Breed
unknown
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
12. How long did the symptoms last?
Persisted until death
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
Died
16. How was the animal exposed?
Other / Autre
specify unknown
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
The pet (Siamese Cat) was out of the house during the tenting on 7/29 and was brought into the home on 8/1. The pets bedding, food and litter box were all out of the house. There was a dead gecko laying in the pet's bed. The pet is asymptomatic and eating and drinking normally.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
The medical professional indicated the following: Because the time course was poorly consistent, the amount was unknown consistent, and the findings were poorly consistent, this substance was considered to have doubtful likelihood of causing the clinical situation.