Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2014-4141
2. Registrant Information.
Registrant Reference Number: 2014CK300
Registrant Name (Full Legal Name no abbreviations): Bayer Inc
Address: 77 Belfield Rd
City: Toronto
Prov / State: ON
Country: Canada
Postal Code: M9W 1G6
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
28-JUL-14
5. Location of incident.
Country: CANADA
Prov / State: PRINCE EDWARD ISLAND
6. Date incident was first observed.
28-JUL-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. Unknown
Product Name: advantage (unknown)
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Animal / Usage sur un animal domestique
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
A 11 month female intact jack russell terrier was treated with advantage in July 2014
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
Medical Professional
2. Type of animal affected
Dog / Chien
3. Breed
jack russell terrier
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
0.9
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Skin
9. What was the length of exposure?
>1 wk <=1 mo / > 1 sem < = 1 mois
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Nervous and Muscular Systems
- Symptom - Restlessness
- Symptom - Muscle tremors
- Symptom - Difficulty walking
12. How long did the symptoms last?
Unknown / Inconnu
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
Fully Recovered / Complètement rétabli
16. How was the animal exposed?
Treatment / Traitement
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
shortly after product application, the dog was restless so the owner applied tea tree oil and citronella. the dog developed muscle twitches and couldnt walk. the dog was bathed twice and recovered.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here
The pet owner reported that the dog was treated in May 2014 and was lethargic for a couple of days following product application. When the dog was treated in June 2014, the dog had an episode of vomiting for 2-3 days following product application. Further details are not available.