Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-2369
2. Registrant Information.
Registrant Reference Number: x
Registrant Name (Full Legal Name no abbreviations): x
Address: xx
City: x
Prov / State: x
Country: x
Postal Code: 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: ONTARIO
6. Date incident was first observed.
18-MAY-12
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. 29535
PMRA Submission No.
EPA Registration No.
Product Name: Fiesta Broadleaf Herbicide and Fertilizer
- Active Ingredient(s)
- IRON (PRESENT AS FEHEDTA)
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
Préciser le type: lawn
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Caller reported that Weed Man attended her property on May 18 and sprayed the front lawn and backyard with environmentally friendly Fiesta Broadleaf Herbicide and Fertilizer. A sign was posted on the front yard.
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
Other
2. Type of animal affected
Dog / Chien
3. Breed
4. Number of animals affected
1
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
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- General
- Symptom - Malaise
- Specify - ill
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
Unknown
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?
Accidental ingestion/Ingestion accident.
specify Exposure not described
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Her dog was let out in the backyard later that day. When she returned from work her dog was very ill and was taken to the vet where the dog later died. Tests from the vet indicate that the dog was poisoned with ethylene glycol. The caller advised that tests on Fiesta could produce a false positive for ethylene glycol. Lab analysis from the vet were not provided to the Ministry for review. The Caller has requested the vet not cremate her dog yet in case there is a chance for further tests to be done to determine the cause of death. Caller has retained a sample of vomit from her dog for analysis.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Not Applicable
19. Provide supplemental information here