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Consumer Product Safety

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
    • Symptom - Seizure
  • General
    • Symptom - Death

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