Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-2751
2. Registrant Information.
Registrant Reference Number: 15062801
Registrant Name (Full Legal Name no abbreviations): Nufarm Agriculture Inc.
Address: 5507 1st Street SE
City: Calgary
Prov / State: Alberta
Country: Canada
Postal Code: T2H 1H9
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
28-JUN-15
5. Location of incident.
Country: CANADA
Prov / State: BRITISH COLUMBIA
6. Date incident was first observed.
28-JUN-15
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. 27972
PMRA Submission No.
EPA Registration No.
Product Name: Nufarm Trillion Turf Herbicide
- Active Ingredient(s)
- 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)
- DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, OR SODIUM SALT)
- MECOPROP-P (PRESENT AS DIMETHYLAMINE SALT)
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: Agricultural-Outdoor/Agricole-extérieur
Préciser le type: unknown
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Product was applied along a ditch with a small quad-mounted estate. Drift might have reached water present in the ditch.
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Unknown
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
unknown
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
Oral
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
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
Fully Recovered / Complètement rétabli
16. How was the animal exposed?
Spray drift / Dérive de pulvérisation
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Dow was kept off the applied site for 24 hours. After releasing the dog owner saw him vomiting, however few hours after dog was looking normal. Owner did not see him drinking contaminated water, he also was wondering if dog was vomiting due to excessive heat.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here