Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-1038
2. Registrant Information.
Registrant Reference Number: A120121788
Registrant Name (Full Legal Name no abbreviations): Dow AgroSciences Canada Inc.
Address: Suite 2100, 450 - 1 Street S.W.
City: Calgary
Prov / State: Alberta
Country: Canada
Postal Code: T2P 5H1
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
30-AUG-12
5. Location of incident.
Country: UNITED STATES
Prov / State: KENTUCKY
6. Date incident was first observed.
28-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. 62719-260-34704
Product Name: Crossbow L Herbicide
- Active Ingredient(s)
- 2,4-D (PRESENT AS LOW VOLATILE ESTERS)
- Guarantee/concentration 34.4 %
- TRICLOPYR
- Guarantee/concentration 16.5 %
7. b) Type of formulation.
Liquid
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).
The exposure was accidental and occurred at animal owner's yard. Owner sprayed an area in the yard with a slighter more concentrated solution than the label recommends. Dogs would have had access to treated areas right away. They did smell like the agent prior to bathing.
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
Other
2. Type of animal affected
Dog / Chien
3. Breed
Chihuahua (Canine Domestic)
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
1
7. Weight (provide a range if necessary )
4.3
lbs
8. Route(s) of exposure
Oral
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 - Recumbent
- Symptom - Ataxia
- Skin
- Symptom - Pale mucous membrane colour
- Eye
- Symptom - Pupil dilation
- Specify - Mydriasis
- Symptom - Other
- Specify - corneal ulceration
- Nervous and Muscular Systems
- Blood
- Symptom - Leukopenia
- Specify - neutropenia
- Symptom - Hyperglycemia
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?
Unknown
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
Exposure involved unknown amount dermally. The exposure was accidental, and occurred at animal owner yard.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
Because the time course was poorly consistent, the amount was unknown and the findings were poorly consistent, this substance was considered to have doubtful likelihood of causing the clinical situation.
Subform III: Domestic Animal Incident Report
1. Source of Report
Other
2. Type of animal affected
Dog / Chien
3. Breed
Golden Retriever (Canine Domestic)
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
10
7. Weight (provide a range if necessary )
56
lbs
8. Route(s) of exposure
Oral
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
- Nervous and Muscular Systems
- Liver
- Symptom - Elevated liver enzymes
- Specify - elevated alkaline phosphatase
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?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Exposure involved unknown amount dermally. The exposure was accidental, and occurred at animal owner yard.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
19. Provide supplemental information here
Because the time course was poorly consistent, the amount was unknown and the findings were poorly consistent, this substance was considered to have doubtful likelihood of causing the clinical situation.
Subform III: Domestic Animal Incident Report
1. Source of Report
Other
2. Type of animal affected
Dog / Chien
3. Breed
Chihuahua (Canine Domestic)
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
2.5
7. Weight (provide a range if necessary )
8.7
lbs
8. Route(s) of exposure
Oral
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Eye
- Symptom - Pupil dilation
- Specify - mydriasis
- Symptom - Other
- Specify - corneal ulceration
- Gastrointestinal System
- Symptom - Diarrhea
- Symptom - Vomiting
- Eye
- Symptom - Other
- Specify - anisocoria
- Liver
- Symptom - Elevated liver enzymes
- Specify - elevated alkaline phosphatase
- Nervous and Muscular Systems
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?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Exposure involved unknown amount dermally. The exposure was accidental, and occurred at animal owner yard.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
19. Provide supplemental information here
Because the amount was unknown consistent, the patient was considered to be at medium risk of developing clinical signs. If signs develop, there is low risk that those signs will be life-threatening.