Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-0344
2. Registrant Information.
Registrant Reference Number: 110008855
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.
21-JAN-11
5. Location of incident.
Country: UNITED STATES
Prov / State: HAWAII
6. Date incident was first observed.
21-JAN-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).
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
Dog / Chien
3. Breed
Labrador Retriever Mix
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
5
7. Weight (provide a range if necessary )
5
lbs
8. Route(s) of exposure
Respiratory
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Bloody diarrhea
- Symptom - Vomiting
- Nervous and Muscular Systems
- Symptom - Fasciculations
- Symptom - Seizure
- Symptom - Semi comatose
- Symptom - Abnormal gait
- Skin
- Symptom - Pale mucous membrane colour
- Specify - Injected Mucous Membranes
- Symptom - Erythema
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?
1
Day(s) / Jour(s)
15. Outcome of the incident
Died
16. How was the animal exposed?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
The dog got loose during the exposure period. There was an area in the rear of the house that was taped and sealed to some steps but the dog scratched its way inside at that area. The house was fumigated and was being "un tented" but not cleared for entry when the dog went in. The patient died early Saturday (1/22) prior to 8am local time.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here