Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2014-1092
2. Registrant Information.
Registrant Reference Number: 764122
Registrant Name (Full Legal Name no abbreviations): Bayer CropScience Inc.
Address: #200, 160 Quarry Park Blvd SE
City: Calgary
Prov / State: AB
Country: Canada
Postal Code: T2C 3G3
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
17-MAR-11
5. Location of incident.
Country: UNITED STATES
Prov / State: GEORGIA
6. Date incident was first observed.
17-DEC-10
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. 432-1251
Product Name: MaxForce Small Roach Stations
- Active Ingredient(s)
- HYDRAMETHYLNON
- Guarantee/concentration 2 %
7. b) Type of formulation.
Bait
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
Other
2. Type of animal affected
Dog / Chien
3. Breed
Unknown
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
1.50
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Oral
9. What was the length of exposure?
<=15 min / <=15 min
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Rectal hemorrhage
- Symptom - Vomiting
- Respiratory System
- Symptom - Shortness of breath
- Symptom - Difficulty Breathing
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?
Accidental ingestion/Ingestion accident.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
3/17/2011
Caller is a pest control officer calling regarding a dog that chewed on a bait station that was placed by the pest control company on 12/29/2010. An unknown amount of time later, the dog developed rectal bleeding, vomiting, and difficulty breathing. The dog died on 2/14/2011. The dog was never evaluated by a veterinarian.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here