Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-2779
2. Registrant Information.
Registrant Reference Number: 2013-8
Registrant Name (Full Legal Name no abbreviations): BASF Canada
Address: 100 Milverton, 5th floor
City: Mississauga
Prov / State: ON
Country: Canada
Postal Code: L5R4H1
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
15-MAY-13
5. Location of incident.
Country: UNITED STATES
Prov / State: NORTH CAROLINA
6. Date incident was first observed.
15-MAY-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. 7969-285
Product Name: Phantom
7. b) Type of formulation.
Other (specify)
pressurized spray
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Res. - In Home / Rés. - à l'int. maison
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Product applied May 10 inside dwelling; rabbits housed in cages inside dwelling dead May 15.
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
Other / Autre
specify rabbit
3. Breed
domestic
4. Number of animals affected
2
5. Sex
Unknown
6. Age (provide a range if necessary )
0.17
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
>3 days <=1 wk / >3 jours <=1 sem
10. Time between exposure and onset of symptoms
>3 days <=1 wk / >3 jours <=1 sem
11. List all symptoms
System
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?
Spray drift / Dérive de pulvérisation
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
2 rabbits died 5 days after treatment in home
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 consistent, and the findings were poorly consistent, this substance was considered to have doubtful likelihood of causing the clinical situation.