Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-5975
2. Registrant Information.
Registrant Reference Number: 841954
Registrant Name (Full Legal Name no abbreviations): Bayer CropScience Inc.
Address: 295 Henderson Drive
City: Regina
Prov / State: SK
Country: Canada
Postal Code: S4N 6C2
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
23-AUG-11
5. Location of incident.
Country: UNITED STATES
Prov / State: WASHINGTON
6. Date incident was first observed.
30-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)
PMRA Registration No.
PMRA Submission No.
EPA Registration No. 72155-27
Product Name: Home Pest Control Indoor+Outdoor Insect Killer(1gal pump spray)
- Active Ingredient(s)
- CYFLUTHRIN
- Guarantee/concentration .05 %
7. b) Type of formulation.
Liquid
Application Information
8. Product was applied?
Yes
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
Miniature Poodle
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
14
7. Weight (provide a range if necessary )
22.00
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
<=15 min / <=15 min
10. Time between exposure and onset of symptoms
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Diarrhea
- Symptom - Vomiting
- General
- Symptom - Dehydration
- Symptom - Fever
- Nervous and Muscular Systems
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
Yes
14. b) How long was the animal hospitalized?
4
Day(s) / Jour(s)
15. Outcome of the incident
Died
16. How was the animal exposed?
Other / Autre
specify No known point of exposure has been indentified. Exposure is speculative and based off of animal possibly entering an area where pesticide had been used.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
8/23/2011 Caller used the product around the perimeter of the home (outside) 3 days prior to the dog eating grass somewhere in their yard on 7/30/11. Dog developed vomiting and diarrhea within 24 hours. Evaluation at clinic 8/2/11 showed dehydration. Dog was admitted to the hospital on IV fluids, antibiotics and anti-emetic. He developed a high fever 8/6/11 and died on his own. No necropsy performed.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here