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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-2766

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-33517469

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.

30-APR-13

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

6. Date incident was first observed.

30-APR-13

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

  • Active Ingredient(s)
    • METALDEHYDE
      • Guarantee/concentration 3.25 %

7. b) Type of formulation.

Other (specify)

Pellets

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

Mixed Breed

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

4

7. Weight (provide a range if necessary )

9

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 - Anxiety
  • General
    • Symptom - Death
  • Nervous and Muscular Systems
    • Symptom - Shaking
    • Symptom - Unresponsive
    • Symptom - Seizure
  • General
    • Symptom - Fever
  • Nervous and Muscular Systems
    • 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?

2

Day(s) / Jour(s)

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

1-33517469 - The reporter, a pet owner, indicated that his dog was exposed to a molluscicide containing the active ingredient metaldehyde. The reporter indicated that the product was applied outside his home on the day of initial contact. The reporters 4-year-old, 9 pound, mixed breed dog was later seen at the application site eating something. At the time of initial contact the reporter stated that for the past 30 minutes his dog had been ataxic, was shaking and non-responsive. The reporter was advised to seek immediate veterinary care. On follow up call, one day later, the pet owner indicated that the dog was taken to the ER on the evening of initial contact where it also suffered from seizures and a fever. The dog was treated at the ER and was doing better the following morning. The reporter then transferred his dog to his regular veterinarian for care where it stayed for the day and through the night. The following morning the veterinary staff found the dog dead in its kennel. The reporter indicated that he did not think the dog was being monitored closely enough. 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