Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-2863
2. Registrant Information.
Registrant Reference Number: 2015TH012
Registrant Name (Full Legal Name no abbreviations): Bayer Inc
Address: 2920 Matheson Blvd E
City: Mississauga
Prov / State: ON
Country: Canada
Postal Code: L4W 5R6
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
16-APR-15
5. Location of incident.
Country: CANADA
Prov / State: BRITISH COLUMBIA
6. Date incident was first observed.
06-APR-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. 29779
PMRA Submission No.
EPA Registration No.
Product Name: K9 advantix II extra large dog
- Active Ingredient(s)
- IMIDACLOPRID
- PERMETHRIN
- PYRIPROXYFEN
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
4
Units: mL
10. Site pesticide was applied to (select all that apply).
Site: Animal / Usage sur un animal domestique
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?
Yes
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Leonberger
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
2
7. Weight (provide a range if necessary )
61
kg
8. Route(s) of exposure
Skin
9. What was the length of exposure?
>1 wk <=1 mo / > 1 sem < = 1 mois
10. Time between exposure and onset of symptoms
>1 wk <=1 mo / > 1 sem < = 1 mois
11. List all symptoms
System
- Nervous and Muscular Systems
- Symptom - Trembling
- Symptom - Difficulty getting up
- Specify - unable to stand
- Renal System
- Symptom - Creatinine increased
- Blood
- Symptom - Blood urea nitrogen increased
- Specify - BUN elevated
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
Yes
14. b) How long was the animal hospitalized?
2
Day(s) / Jour(s)
15. Outcome of the incident
Euthanised / Euthanasie
16. How was the animal exposed?
Treatment / Traitement
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
On March 24 2015 a pet owner applied 1 tube of K9 advantix II XL to a 2 yr old 61 kg F Leonberger. On April 5 the dog was taken to a river to play. April 6 the pet owner noticed the dogs eyes were red. April 7 the dog was examined and treated for the red eye. April 9 the dog began to tremble and was unable to stand. April 10 the dog was not eating and seemed to be painful and was admitted to hospital. The pet was placed on IV fluids and bloodwork showed elevated BUN and CREA. The dog did not have any significant urine production. There was no evidence of anti-freeze toxicity and vector borne disease testing and lepto tests were negative. April 11 the pet owner s elected euthanasia
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here