Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-3448
2. Registrant Information.
Registrant Reference Number: 976175
Registrant Name (Full Legal Name no abbreviations): Bayer CropScience Inc.
Address: 295 Henderson Drive
City: Regina
Prov / State: SK
Country: Canada
Postal Code: S4N 6C2
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
18-MAY-12
5. Location of incident.
Country: UNITED STATES
Prov / State: INDIANA
6. Date incident was first observed.
18-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.
EPA Registration No. 3125-506-72155
Product Name: Power Force Multi-Insect Granules 10 lb
- Active Ingredient(s)
- CYFLUTHRIN
- Guarantee/concentration .1 %
7. b) Type of formulation.
Granular
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).
Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding application.
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
Pit Bull Terrier
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
1.50
7. Weight (provide a range if necessary )
25.00
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
<=15 min / <=15 min
10. Time between exposure and onset of symptoms
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Bloody stool
- Symptom - Diarrhea
- Symptom - Melena
- Symptom - Vomiting
- General
- Symptom - Death
- Symptom - Lethargy
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
5/18/2012
Caller reports that their yard was treated with the product around May 11. One of caller's dogs was out in the yard almost immediately after treatment. The next day, the dog developed vomiting and bloody stool. The symptoms progressed to bloody diarrhea and melena. The dog died this morning, and was never taken to a veterinarian despite the severity of his illness.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here