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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-0828

2. Registrant Information.

Registrant Reference Number: PROSAR Case#: 1-25838361

Registrant Name (Full Legal Name no abbreviations): Valent Canada, Inc.

Address: 6-130 Research Lane

City: Guelph

Prov / State: Ontario

Country: Canada

Postal Code: N1G 5G3

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

Domestic Animal

4. Date registrant was first informed of the incident.


5. Location of incident.


Prov / State: TENNESSEE

6. Date incident was first observed.


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.


PMRA Registration No.       PMRA Submission No.       EPA Registration No. 59639-99

Product Name: Valor Herbicide

  • Active Ingredient(s)

7. b) Type of formulation.


Application Information

8. Product was applied?


9. Application Rate.


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?


Subform III: Domestic Animal Incident Report

1. Source of Report


2. Type of animal affected

Dog / Chien

3. Breed


4. Number of animals affected


5. Sex


6. Age (provide a range if necessary )


7. Weight (provide a range if necessary )


8. Route(s) of exposure


9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>8 hrs <=24 hrs / > 8 h < = 24 h

11. List all symptoms


  • General
    • Symptom - Death

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.


14. a) Was the animal hospitalized?


14. b) How long was the animal hospitalized?

15. Outcome of the incident


16. How was the animal exposed?

Spray drift / Dérive de pulvérisation

17. Provide any additional details about the incident

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

1-25838361- The reporter, an employee of a (name), reports an animal may have been exposed to an herbicide containing the active ingredient flumioxizin. The reporter stated he had been contacted by the customer that had purchased/applied the product. The customer stated he had diluted the product at a ratio of 2oz of product to 10 gallons of water and had subsequently sprayed his property two days prior to the initial contact with the registrant. The rate of application and the nature of the property (agricultural, residential, etc) were not disclosed. The customer stated his neighbors dog had been tied up in his yard within ten feet of the application area during the application. The pet owner had told the customer that the pet had died the same day of application. The signalment of the animal was not described. Signs leading up to the animal's death were not described. Any veterinary care provided was not described. The customer had stated the only potential exposure that may have been possible would be inhalation of drift. The reporter was advised the level of exposure as described would be expected to yield no more than mild respiratory irritation. Sudden death would not be expected. Something else was likely affecting the animals health. No further information is available.

To be determined by Registrant

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


19. Provide supplemental information here