Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-1404
2. Registrant Information.
Registrant Reference Number: PROSAR case #: 1-32284638
Registrant Name (Full Legal Name no abbreviations): Syngenta Canada Inc.
Address: 140 Research Lane, Research Park
City: Guelph
Prov / State: Ontario
Country: Canada
Postal Code: N1G4Z3
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
14-DEC-12
5. Location of incident.
Country: UNITED STATES
Prov / State: WASHINGTON
6. Date incident was first observed.
12-DEC-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. 100-1055
Product Name: Weatherblok XT Rodenticide
- Active Ingredient(s)
- BRODIFACOUM
- Guarantee/concentration .005 %
7. b) Type of formulation.
Bait
Application Information
8. Product was applied?
No
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
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
Other
2. Type of animal affected
Dog / Chien
3. Breed
Unknown
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
15
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
- 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?
Accidental ingestion/Ingestion accident.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1-32284638 - The reporter, a property owner, indicated that a stray dog may have been exposed to a rodenticide containing the active ingredient brodifacoum. The reporter indicated that a 15 pound stray dog had become lethargic and then was found dead in a pool of blood on his property two days prior to initial contact with the registrant. The reporter did not witness ingestion of the registrant product but indicates that the bait is now missing from the container. The reporter believes that the animal had access to the stock and within 10-12 hours after access to the area became lethargic. The reporter was advised that the substance takes 2-5 days to take effect and symptoms would not be expected 10-12 hours after exposure. Necropsy was discussed to help determine the cause of death but the reporter indicated that the dog had been cremated. 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