Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-0886
2. Registrant Information.
Registrant Reference Number: 1516115
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.
09-DEC-14
5. Location of incident.
Country: UNITED STATES
Prov / State: ARIZONA
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. 72155-21
Product Name: All-in-One Rose & Flower Care
- Active Ingredient(s)
- IMIDACLOPRID
- Guarantee/concentration .8 %
- TEBUCONAZOLE
- Guarantee/concentration .8 %
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. - Out Home / Rés - à l'ext.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
Mixed Breed
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
2
7. Weight (provide a range if necessary )
14.00
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>1 wk <=1 mo / > 1 sem < = 1 mois
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Diarrhea
- Symptom - Melena
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?
Unknown
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
12/9/2014 Caller applied the product to her rose bushes about a month ago. Caller's dog began vomiting foam and saliva repeatedly 3 nights ago. The next day the dog had bloody diarrhea. The dog was brought to the veterinarian. Blood tests were performed, and found that phosphorus levels and white blood cell count were high. The dog was given antibiotics, pain medication, and fluid therapy. The dog died that evening. Caller also used a granular grub product that the veterinarian check into, but ruled out as the cause of death.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here