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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-5730

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: x

City: x

Country: x

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

6. Date incident was first observed.

13-AUG-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. 24984      PMRA Submission No.       EPA Registration No.

Product Name: Matador

  • Active Ingredient(s)
    • LAMBDA-CYHALOTHRIN

PMRA Registration No. 30332      PMRA Submission No.       EPA Registration No.

Product Name: Vertisan Fungicide

  • Active Ingredient(s)
    • PENTHIOPYRAD

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: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: sunflowers

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Aerial application on sunflowers - Spray drift complaint.

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

Other

2. Type of animal affected

Fish / Poisson

3. Breed

Trout (farmed)

4. Number of animals affected

200

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

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

11. List all symptoms

System

  • General
    • Symptom - Death
  • Gastrointestinal System
    • Symptom - Anorexia
    • Specify - not feeding

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?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

16. How was the animal exposed?

Spray drift / Dérive de pulvérisation

17. Provide any additional details about the incident

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

Within 48 hours of application, fish appeared to be no longer feeding. Following day fish were dying. No medical treatment was provided. Fish may have been exposed due to spray drift of the adjacent sunflower field. Owner indicated spraying occurred around 7:00pm. All seven ponds were affected. He reported residue could be seen on surface of pond waters. Unknown on the amount of fish they were exposed to.


To be determined by Registrant

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

Not Applicable

19. Provide supplemental information here