Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-0795
2. Registrant Information.
Registrant Reference Number: 1493899
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.
01-NOV-14
5. Location of incident.
Country: CANADA
Prov / State: SASKATCHEWAN
6. Date incident was first observed.
31-OCT-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. 30668
PMRA Submission No.
EPA Registration No.
Product Name: STRESS SHIELD 600 (CANADA)
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: Other / Autre
Préciser le type: Grain
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
Boxer
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
2
7. Weight (provide a range if necessary )
60.00
lbs
8. Route(s) of exposure
Oral
9. What was the length of exposure?
<=15 min / <=15 min
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Nervous and Muscular Systems
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
No
14. b) How long was the animal hospitalized?
Unknown
15. Outcome of the incident
Unknown/Inconnu
16. How was the animal exposed?
Accidental ingestion/Ingestion accident.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
11/1/2014 Caller's dog ingested grain that was treated with the products 12 hours ago. Caller estimates that about 1 cup of the treated grain was ingested. The grain was partially rotten, and may have contained mold. The dog was asymptomatic overnight, but this morning has rear limb ataxia. Caller has not contacted the veterinarian yet.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
19. Provide supplemental information here