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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-0034

2. Registrant Information.

Registrant Reference Number: 1432447

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.

28-JUL-14

5. Location of incident.

Country: UNITED STATES

Prov / State: OHIO

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)

PMRA Registration No.       PMRA Submission No.       EPA Registration No. 72155 80

Product Name: Home Pest plus Germ Killer Indoor & Outdoor Killer RTU 1 Gal

  • Active Ingredient(s)
    • CYFLUTHRIN
      • Guarantee/concentration .05 %
    • SODIUM O-PHENYLPHENATE
      • Guarantee/concentration .3 %

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. - 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

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Shih Tzu

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

3

7. Weight (provide a range if necessary )

10.00

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

  • Gastrointestinal System
    • Symptom - Anorexia
  • General
    • Symptom - Death
    • Symptom - Fever
    • Symptom - Lethargy
  • Nervous and Muscular Systems
    • Symptom - Ataxia
    • Symptom - Seizure

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?

No

14. b) How long was the animal hospitalized?

Unknown

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

7/28/2014 The manufacturer was notified by a consumer of an event involving her dog after the product was applied in the home for bed bugs. No additional information was provided. The manufacturer forwarded consumer's information for follow up. Attempted call to the consumer. A message was left requesting follow up information. Caller returned the previous message. She is at work and cannot discuss the issue at this time. 7/29/2014 Caller sprayed the product around the baseboards in her home on or around 7/18/2014. The dog started to have seizures on 7/23/2014, and was taken to the veterinarian at that time. The dog did not have any witnessed exposure. The dog had a fever of 105.4 degrees Fahrenheit. The dog was given several unknown injections for treatment at that time. The dog was taken again to the veterinarian yesterday for continued seizures. The veterinarian gave an unknown injection to stop the seizures, and the dog has had no further seizures. Blood work was done at that time, but the results are not yet available. When asked for the diagnosis, the caller stated that the veterinarian indicated that the dog had been poisoned by a spray in the household. The dog remained somewhat ataxic, but is not eating and not currently on any medications. 7/31/2014 The dog died last night.


To be determined by Registrant

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

Death

19. Provide supplemental information here