Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-1850
2. Registrant Information.
Registrant Reference Number: 2012-5
Registrant Name (Full Legal Name no abbreviations): BASF Canada
Address: 100 Milverton, 5th floor
City: Mississauga
Prov / State: ON
Country: Canada
Postal Code: L5R4H1
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
03-MAY-12
5. Location of incident.
Country: UNITED STATES
Prov / State: PENNSYLVANIA
6. Date incident was first observed.
03-MAY-12
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. 2010-0613
EPA Registration No.
Product Name: Phantom
7. b) Type of formulation.
Liquid
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).
Agent applied by PCO; PCO described as sprayed lightly. Did not spray bathroom where dogs were confined. Sprayed in apt around cracks and crevices and around stove and baseboards.
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
Other
2. Type of animal affected
Dog / Chien
3. Breed
Chihuahua
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
3
7. Weight (provide a range if necessary )
1.5
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
>2 hrs <=8 hrs / >2 h <=8 h
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?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
PCO sprayed an APT in AM, owner put 2 chihuahua dogs in bathroom (only 1 which died, reported here); when owner returned, one of dogs was dead.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
Chlorfenapyr has unknown likelihood of causing clinical situation