Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-2713
2. Registrant Information.
Registrant Reference Number: 2012TH058
Registrant Name (Full Legal Name no abbreviations): Bayer Inc
Address: 77 Belfield Rd
City: Toronto
Prov / State: ON
Country: Canada
Postal Code: M9W 1G6
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
22-MAY-12
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
19-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. 27661
PMRA Submission No.
EPA Registration No.
Product Name: K9 advantix 20
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
1
Units: mL
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).
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Yes
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Miniature Poodle
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
4.5
7. Weight (provide a range if necessary )
14.3
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
>1 mo <= 6 mos / > 1 mois < = 6 mois
10. Time between exposure and onset of symptoms
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- Skin
- Symptom - Itchy skin
- Symptom - Red skin
- Nervous and Muscular Systems
- Symptom - Seizure
- Symptom - Loss of coordination
- Specify - dog seemed uncoordinated
- Renal System
- Symptom - Inappropriate urination
12. How long did the symptoms last?
>24 hrs <=3 days / >24 h <=3 jours
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
Fully Recovered / Complètement rétabli
16. How was the animal exposed?
Treatment / Traitement
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Owner applied product the evening of May 18th. May 19 she noticed the pet was itchy at the application site and the site was a bit red. She rinsed the pet with water but did not apply vitamin E as was suggested by her vet. May 20th the owner feels the dog had a seizure. The owner was in the kitchen when the dog ran in from another room in the house. The dog seem uncoordinated and drooling and was stiff when the owner picked it up. After about a minute the owner placed the dog on the floor and it fell over. It then got up and went outside and urinated and defecated. The owner later found urine on the floor where she thinks the dog may have been laying before this episode.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Major
19. Provide supplemental information here