Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-3745
2. Registrant Information.
Registrant Reference Number: PROSAR Case #: 1-31170614
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.
09-AUG-12
5. Location of incident.
Country: UNITED STATES
Prov / State: OREGON
6. Date incident was first observed.
09-AUG-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. 8119-13
Product Name: Corrys Slug/Snail Pellets MP (non-specific)
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).
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
Miniature Schnauzer
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
5
7. Weight (provide a range if necessary )
25
lbs
8. Route(s) of exposure
Oral
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
<=30 min / <=30 min
11. List all symptoms
System
- Nervous and Muscular Systems
- Symptom - Trembling
- Symptom - Seizure
- Symptom - Ataxia
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
Yes
14. b) How long was the animal hospitalized?
Unknown
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
1-31170614 - The reporter, a pet owner, indicated that her dog was exposed to a molluscicide product containing the active ingredient metaldehyde. The pet owner reported that the product was applied in the garden 30 minutes prior to initial contact and at the time of the call they had just found their 5-year-old, female schnauzer in the garden shaking, breathing hard, ataxic and seizing intermittently. The reporter was advised to seek immediate veterinary care. On follow up call, one day later, the reporter indicated that the dog was taken to a veterinarian but died on its own in the middle of the night at the clinic. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here