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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-0538

2. Registrant Information.

Registrant Reference Number: 1276640

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.

03-NOV-13

5. Location of incident.

Country: UNITED STATES

Prov / State: NEW YORK

6. Date incident was first observed.

01-NOV-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. 432-1377

Product Name: Tempo Ultra WSP

  • Active Ingredient(s)
    • CYFLUTHRIN
      • Unknown

7. b) Type of formulation.

Wettable or soluble powder

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).

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?

Yes

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Yorkshire Terrier (Yorkie)

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

1.50

7. Weight (provide a range if necessary )

3.00

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

<=15 min / <=15 min

10. Time between exposure and onset of symptoms

>24 hrs <=3 days / >24 h <=3 jours

11. List all symptoms

System

  • Gastrointestinal System
    • Symptom - Bloating
    • Symptom - Vomiting
  • General
    • Symptom - Death

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?

No

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

11/3/2013 Caller states that this product was used in her home on 11/1/2013. Caller states that the following morning after it was used in the home, the dog became bloated and vomited. The dog was taken to the veterinarian, and they could not find anything wrong with her so she was sent home. Caller was told to monitor the dog and to bring her back in if signs develop again. Caller states the dog then vomited again so she took her back into the veterinarian. Unspecified blood testes were done and they could not find anything abnormal. Caller states the dog is at home now and has not vomited since yesterday. 11/8/2013 Callback to the original caller for follow up information. The dog was taken to the veterinarian and had blood work and x-rays. All results came back normal. Then two days ago the dog died at home.


To be determined by Registrant

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

Death

19. Provide supplemental information here