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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2013-4629
2. Registrant Information.
Registrant Reference Number: 1192600
Registrant Name (Full Legal Name no abbreviations): Bayer CropScience Inc.
Address: 295 Henderson Drive
City: Regina
Prov / State: SK
Country: Canada
Postal Code: S4N 6C2
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
24-JUN-135. Location of incident.
Country: UNITED STATES
Prov / State: TEXAS
6. Date incident was first observed.
Unknown
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. 72155-29
Product Name: Complete Insect Killer for Soil & Turf (Ready-to-Spray) 32 fl oz
- Active Ingredient(s)
- CYFLUTHRIN
- Guarantee/concentration .36 %
- IMIDACLOPRID
- Guarantee/concentration .72 %
- CYFLUTHRIN
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).
Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding application.To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
YesSubform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Pomeranian
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
9
7. Weight (provide a range if necessary )
15.00
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Respiratory System
- Symptom - Nose bleed
- Gastrointestinal System
- Symptom - Bloody stool
- Symptom - Diarrhea
- Symptom - Vomiting
- General
- Symptom - Death
- Symptom - Dehydration
- Nervous and Muscular Systems
- Symptom - Seizure
- Respiratory System
- Symptom - Shortness of breath
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?
Unknown
15. Outcome of the incident
Died
16. How was the animal exposed?
Other / Autre
specify Defined point of exposure not evident or witnessed. Exposure based on speculation.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
6/24/2013 Caller applied the product last night on plants and flowerbeds. The dog was in the yard this morning and the lawn was still damp, and may have been outside last night as they have a dog door allowing free access. This morning the dog developed vomiting, diarrhea, and shortness of breath. The dog was taken to the veterinarian where intravenous fluids were started and blood work and chest radiographs are pending. Received a follow-up call from the treating veterinarian. The dog is very dehydrated on presentation, has blood in her stools, bleeding from her nose, and still vomiting and having shortness of breath. Follow-up with owner completed on 7/10/2013. Two hours after speaking to the veterinarian, the dog started convulsing and died. The veterinarian does not believe the product was the cause, and suspects rat poison or a cancerous mass that burst, but actual cause is unknown.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
