Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-2963
2. Registrant Information.
Registrant Reference Number: PROSAR case #: 1-40881559
Registrant Name (Full Legal Name no abbreviations): Syngenta Canada Inc.
Address: 140 Research Lane, Research Park
City: Guelph
Prov / State: Ontario
Country: Canada
Postal Code: N1G4Z3
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
11-JUN-15
5. Location of incident.
Country: CANADA
Prov / State: QUEBEC
6. Date incident was first observed.
11-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. 26980
PMRA Submission No.
EPA Registration No.
Product Name: Vanquish Herbicide
- Active Ingredient(s)
- DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, OR SODIUM 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: 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).
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
Other
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
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Vomiting
- Symptom - Diarrhea
- Nervous and Muscular Systems
- Symptom - Muscle weakness
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?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Fully Recovered / Complètement rétabli
16. How was the animal exposed?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1-40881559 - The reporter, a pest control operator, indicated that a dog was exposed to an herbicide containing the active ingredient dicamba. The reporter applied the product to the customers lawn at some unspecified time. The customers dog entered the application site 24 hours after the product had been applied and at the time of the call the dog was weak, vomiting and had diarrhea. The reporter indicated that the dog had been under the care of a veterinarian for a period of 2 days. On follow-up call, four days later, the reporter indicated that the dogs symptoms had resolved. No additional information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here
Label directions were not followed because this product is not registered for domestic use.