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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-2440

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: x

City: x

Prov / State: x

Country: x

Postal Code: X

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA


6. Date incident was first observed.


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.


PMRA Registration No.       PMRA Submission No.       EPA Registration No.

Product Name:

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


10. Site pesticide was applied to (select all that apply).

Site: Res. - Out Home / Rés - à l'

Préciser le type: yard

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Last spring she moved with her dog from downtown (city) to a property in (city) with a large yard. The woman that owned the property was apprerently spraying the yard with moss killer the day she let her dog out on the lawn to frolic around.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?


Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed


4. Number of animals affected


5. Sex


6. Age (provide a range if necessary )


7. Weight (provide a range if necessary )


8. Route(s) of exposure


9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>2 mos <=6 mos / > 2 mois < = 6 mois

11. List all symptoms


  • General
    • Symptom - Death
  • Blood
    • Symptom - Bleeding
    • Specify - bleeding from anus
  • General
    • Symptom - Cancer
    • Specify - bladder cancer

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.


14. a) Was the animal hospitalized?


14. b) How long was the animal hospitalized?

15. Outcome of the incident


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

I received a phone call from a woman last week who was concerned about the liberal use of moss killer without the need for posting warning signs etc. She claimed that her 12 year old Maltese dog died as a result of exposure to moss killer containing ferrous sulphate heptahydrate. Last spring she moved with her dog from downtown (city) to a property in (city) (rural) with a large yard. The woman that owned the property was apprently spraying the yard with moss killer the day she let her dog out on the lawn to frolic around. The dog did come in contact with the wet spray. For the next two months the dog was often outside and allowed free run of the yard. By the third month the dog started bleeding from the anus and was diagnosed with bladder cancer and died. The Vet gave the woman some information she pulled off the internet which explained that the type of cancer the dog had was caused by pesticides and herbicides.The dog owner called the moss killer manufacturer who happened to be Scotts in the US as the property owner had bought the moss killer in the US. The responder at the emergency information number she found on the package (located in the US) told her that iron is very toxic to dogs. I asked the dog owner if she was interested in filing an incident report, but she was not. When I asked her which vet hospital had given her the information she did tell me, but also asked that I not approach them for any information without talking to her first.

To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Not Applicable

19. Provide supplemental information here