Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-0984

2. Registrant Information.

Registrant Reference Number: 2014-4

Registrant Name (Full Legal Name no abbreviations): BASF Canada

Address: 100 Milverton, 5th floor

City: Mississauaga

Prov / State: Ontario

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.

20-MAR-14

5. Location of incident.

Country: UNITED STATES

Prov / State: NEVADA

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)

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PMRA Registration No. 19525      PMRA Submission No.       EPA Registration No.

Product Name: Maxforce Roach Killer bait gel

• Active Ingredient(s)
  • HYDRAMETHYLNON
    • Unknown

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PMRA Registration No. 30664      PMRA Submission No.       EPA Registration No.

Product Name: Phantom Pr Insecticide spray with IGR

• Active Ingredient(s)
  • CHLORFENAPYR

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7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

9. Application Rate.

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

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

Chihuahua

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

12

7. Weight (provide a range if necessary )

10

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

>1 mo <= 6 mos / > 1 mois < = 6 mois

10. Time between exposure and onset of symptoms

>1 wk <=1 mo / > 1 sem < = 1 mois

11. List all symptoms

System

• Respiratory System
  • Symptom - Sneezing

• Gastrointestinal System
  • Symptom - Vomiting

• Nervous and Muscular Systems
  • Symptom - Stiffness
  • Symptom - Ataxia

• Gastrointestinal System
  • Symptom - Bloody stool

• Nervous and Muscular Systems
  • Symptom - Head shaking

• General
  • Symptom - Rubbing face
  • 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?

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?

Contact treat.area/Contact surf. traitée

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

Owner moved into apt in November, 3 weeks later dog started sneezing occasionally, then later vomiting, evaluated by clinic, gave gi protectants. The developed neurological signs, clinic again-diagnosed thickening of intestines (enteritis/colitis suspected). Potential exposure to Maxforce,Phantom and Deltadust insecticides.

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To be determined by Registrant

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

Death

19. Provide supplemental information here

Jan 28-took to vet; Jan 29-discharged from hospital. Feb 5 took to vet, feb 6 discharged from hospital. Used PCP #s for actives, these are USA products and BASF Canada only has the tech PCP registration, not Maxforce.