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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-0260
2. Registrant Information.
Registrant Reference Number: PROSAR case number: 1-38731757
Registrant Name (Full Legal Name no abbreviations): AMVAC Chemical Corp
Address: 4695 MacArthur Ct, Ste 1200
City: Newport Beach
Prov / State: California
Country: USA
Postal Code: 92660
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
16-JAN-155. Location of incident.
Country: CANADA
Prov / State: ALBERTA
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. 26509 PMRA Submission No. EPA Registration No.
Product Name: Prelude 240
- Active Ingredient(s)
- PERMETHRIN
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: 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).
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
No
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
Unknown
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
6
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Respiratory
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
- Respiratory System
- Symptom - Sneezing
- Symptom - Runny nose
- Skin
- Symptom - Itchy skin
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
Unknown/Inconnu
16. How was the animal exposed?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1-38731757 - The reporter, a pet owner, indicated that her cat was exposed to an insecticide containing the active ingredient permethrin. For the past three months the reporters apartment has been sprayed a total of eight times for bed bugs. The reporter is not exactly sure which products have been sprayed each time but the last application, which occurred on the day of initial contact, involved application of the registrant product. The reporter normally tries to remove her cat from the apartment during application but is not always informed of when the application will occur and one time when the apartment was sprayed and she didnt know it was going to happen the pest control operator just locked her cat in the bathroom. On the day of initial contact, when her apartment was sprayed again without prior consent the pest control operator just let her cat run around the apartment while the products were applied. The reporter indicated that she has noticed that sometime in the last three months her cat started sneezing, has had a runny nose and scratches her skin more frequently. On the day of initial contact the reporter indicated that her cat did not have any additional symptoms in spite of the cats potential exposure to the registrant product earlier that day. No additional information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
