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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-2161
2. Registrant Information.
Registrant Reference Number: PROSAR Case #: 1-29997522
Registrant Name (Full Legal Name no abbreviations): Matson, LLC
Address: 45620 S. E. North Bend Way P.O. Box 1820
City: North Bend
Prov / State: Washington
Country: USA
Postal Code: 98045
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
03-MAY-125. Location of incident.
Country: UNITED STATES
Prov / State: CALIFORNIA
6. Date incident was first observed.
03-MAY-12Product 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. 8119-13
Product Name: Corrys Slug Snail Pellets MP
- Active Ingredient(s)
- METALDEHYDE
- Guarantee/concentration 3.25 %
- METALDEHYDE
7. b) Type of formulation.
Bait
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Res. - Out Home / Rés - à l'ext.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
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
mixed breed
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
10
7. Weight (provide a range if necessary )
15
lbs
8. Route(s) of exposure
Oral
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Nervous and Muscular Systems
- Symptom - Ataxia
- Symptom - Muscle tremors
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Unknown/Inconnu
16. How was the animal exposed?
Accidental ingestion/Ingestion accident.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1-29997522- The reporter, a pet owner, indicated his animals had been exposed to a pesticide containing the active ingredient metaldehyde. The pet owner stated he had applied the product to his lawn earlier in the day. He had allowed his two dogs access to the application area during the course of the day. He assumes the animals ingested the product but did not observe exposure. He returned home at lunch to find his eleven month female eight pound mixed breed dog dead (Sub form III #2). He reports his ten year female fifteen pound mixed breed dog (Sub form III, #1) was at the veterinarian at the point of his initial contact. He had noted ataxia and tremor in the animal. The pet owner was offered the standards of care associated with domestic animal ingestion. The caller was not reached for follow up. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
19. Provide supplemental information here
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Mixed breed
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
0.9
7. Weight (provide a range if necessary )
8
lbs
8. Route(s) of exposure
Oral
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- General
- Symptom - Death
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?
Accidental ingestion/Ingestion accident.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1-29997522- The reporter, a pet owner, indicated his animals had been exposed to a pesticide containing the active ingredient metaldehyde. The pet owner stated he had applied the product to his lawn earlier in the day. He had allowed his two dogs access to the application area during the course of the day. He assumes the animals ingested the product but did not observe exposure. He returned home at lunch to find his eleven month female eight pound mixed breed dog dead (Sub form III #2). He reports his ten year female fifteen pound mixed breed dog (Sub form III, #1) was at the veterinarian at the point of his initial contact. He had noted ataxia and tremor in the animal. The pet owner was offered the standards of care associated with domestic animal ingestion. The caller was not reached for follow up. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
