Health Canada
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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2372

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: x

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.


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.


PMRA Registration No.       PMRA Submission No.       EPA Registration No.

Product Name: Unknown

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


10. Site pesticide was applied to (select all that apply).

Site: Pub. Area - Outdoor/Zone publique - ext

Préciser le type: stream

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?


Subform III: Domestic Animal Incident Report

1. Source of Report


2. Type of animal affected

Horse / Cheval

3. Breed

4. Number of animals affected


5. Sex


6. Age (provide a range if necessary )


7. Weight (provide a range if necessary )


8. Route(s) of exposure


9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms


  • Nervous and Muscular Systems
    • Symptom - Seizure

12. How long did the symptoms last?

>2 hrs <=8 hrs / > 2 h < = 8 h

13. Was medical treatment provided? Provide details in question 17.


14. a) Was the animal hospitalized?


14. b) How long was the animal hospitalized?

15. Outcome of the incident


16. How was the animal exposed?

Contact treat.area/Contact surf. traitée

specify Caller reports she resides at XXXX between XXXXand XXXXX in Ajax. She houses horses on her property and it is reported that since Sunday she has had a number of her horses become violently ill to the point where a couple have almost died. It is reported that they refilled their water troughs on Sunday (water was taken from the river on Wednesday) and believes this may be the cause of the illness as this is the only common denominator between all of the horses.

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

The water used is from XXXX, which has always been the source of water for the horses. The caller has collected a sample of the water that is believed to have caused the horses to get sick and would like to know what to do with it. There was no visible impacts to the creek when the water was taken from the creek. The owner reported that on June 4, 2012, six (6) of her horses became extremely ill. XXXX reported the illness appeared to be neurologic, as the three smallest horse actual seizures for approximately two hours. She is currently operating the farm with 22 riding and jumping horses. The six horses varied in age, but were the smallest in size. XXXX advised that she retained the services of a vet. The vet collected a routine blood sample, but there were no results found to be out of the normal. The horses have started to recover. XXXX reported that the only common source where material could have impacted the horse was from the water they collect from XX. XXXXX reported that they have collected water for the horses from XXX for approximately 15 years. They pump water from the creek into a 500 Litre tote, which is then pumped in the horses outdoor water troughs. . XXXX reported that the water free of any odours and there was no algae in the creek when they pumped the water from the creek. XXXX reported that the water was taken from the creek on Wednesday, May 30, 2012

To be determined by Registrant

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

Not Applicable

19. Provide supplemental information here