Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-6794
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: SASKATCHEWAN
6. Date incident was first observed.
24-NOV-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. 24360
PMRA Submission No.
EPA Registration No.
Product Name: DRAGNET FT EMULSIFIABLE CONCENTRATE
PMRA Registration No. 15255
PMRA Submission No.
EPA Registration No.
Product Name: DRIONE INSECTICIDE DUST
- Active Ingredient(s)
- PIPERONYL BUTOXIDE
- PYRETHRINS
- SILICA AEROGEL
PMRA Registration No. 11540
PMRA Submission No.
EPA Registration No.
Product Name: PRO 3610 ULV INSECTICIDE
- Active Ingredient(s)
- N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
- PIPERONYL BUTOXIDE
- PYRETHRINS
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
.5
Units: L
Other Units: liter/1000sqft.
10. Site pesticide was applied to (select all that apply).
Site: Res. - In Home / Rés. - à l'int. maison
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Dragnet ft - %0.5 applied to cracks and crevices, baseboards and kitchen and bathroom cupboards (total 0.5 liter/1000sqft) Drione - applied to cracks and crevices around kitchen and bathroom areas (4 grams) Pro 3610 ULV - applied to cracks and crevices in ktichen and bathroom areas (5oz).
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
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
12. How long did the symptoms last?
Unknown / Inconnu
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
Unknown/Inconnu
16. How was the animal exposed?
Contact treat.area/Contact surf. traitée
specify Unknown/ animal was not in apartment during treatment and customer was requested to not enter premises for 6 hours after treatment.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Vomiting.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Not Applicable
19. Provide supplemental information here