Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-2512
2. Registrant Information.
Registrant Reference Number: x
Registrant Name (Full Legal Name no abbreviations): x
Address: x
City: x
Prov / State: x
Country: x
Postal Code: X
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
5. Location of incident.
Country: CANADA
Prov / State: NEW BRUNSWICK
6. Date incident was first observed.
03-JUL-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. 26494
PMRA Submission No.
EPA Registration No.
Product Name: Zodiac Powerspot Flea & Tick Control For Dogs under 14 KG (30 lbs)
- Active Ingredient(s)
- (S)-METHOPRENE
- Guarantee/concentration 2.9 %
- PERMETHRIN
- Guarantee/concentration 45 %
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
1
Other Units: tube
10. Site pesticide was applied to (select all that apply).
Site: Animal / Usage sur un animal domestique
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Product was applied as per label to the dog in the house - not directly on cat. Dog and Cat were not separated after application.
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
Cat / Chat
3. Breed
Domestic Shorthair
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>24 hrs <=3 days / >24 h <=3 jours
11. List all symptoms
System
- Nervous and Muscular Systems
- Ear
- Symptom - Other
- Specify - hypersensitivity to sound
- Eye
- Symptom - Photophobia
- Specify - hypersensitivity to light
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Fully Recovered / Complètement rétabli
16. How was the animal exposed?
Other / Autre
specify One tube of <14kg product applied to dog. Cat and dog interact closely, share bedding, etc.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Symptoms started follwing day. Kitten developed full body tremors and hypersensitivity to light and sound. No seizures. Was aware it should not be applied to the cat but did not read all of the tiny print on the package that warned of contact reactions to treated pets. Unknown how exposed, likely skin or oral.Q.8 unknown, likely skin or oral
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Not Applicable
19. Provide supplemental information here