Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2014-1882
2. Registrant Information.
Registrant Reference Number: 1343175
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.
04-MAR-14
5. Location of incident.
Country: UNITED STATES
Prov / State: TEXAS
6. Date incident was first observed.
01-MAR-14
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. 72155-58
Product Name: Power Force Carpenter Ant & Termite Killer Plus Concentrate 32 oz
- Active Ingredient(s)
- CYFLUTHRIN
- Guarantee/concentration 2.5 %
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?
Yes
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Miniature Dachshund
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
7
7. Weight (provide a range if necessary )
14.00
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
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- Respiratory System
- Symptom - Cyanosis
- Symptom - Shortness of breath
- Symptom - Pulmonary edema
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?
4
Day(s) / Jour(s)
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
3/4/2014 Caller states that product was applied behind a garage 5 to 6 years ago. Dog belonging to a family member was found digging in the area 3 days ago. The dog developed shallow breathing the next day. The dog was taken to an emergency clinic and given intravenous fluids and oxygen. Radiographs were done and the results were normal. Blood work was done, and the results are pending. 3/24/2014 Callback attempted to the original caller. A message was left requesting follow up information. 3/27/2014 Call from the original caller. Fluid continued to fill the lungs, and the hypoxic-cyanotic dog was transferred to the regular veterinarian. The dog died 4 days after he was found digging in the area. The veterinarian stated the product was not likely the cause, but they do not know the cause. It is unknown if a necropsy was performed.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here