Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2016-1721
2. Registrant Information.
Registrant Reference Number: 2016CK001
Registrant Name (Full Legal Name no abbreviations): Bayer Inc
Address: 2920 matheson BLVD
City: Mississaugua
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.
06-JAN-16
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
19-DEC-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. 27583
PMRA Submission No.
EPA Registration No.
Product Name: advantage II medium dog
- Active Ingredient(s)
- IMIDACLOPRID
- PYRIPROXYFEN
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
1
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).
A 10year female intact shih Tzu of unknown age was treated with 1 tube of advantage II medium dog on December 17th. The owner reported that the dog had not been eating prior to December 17th but regular went through phases of not eating.
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
shih tzu
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
10
7. Weight (provide a range if necessary )
Unknown
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
>24 hrs <=3 days / >24 h <=3 jours
11. List all symptoms
System
- General
- Symptom - Lethargy
- Symptom - Death
- Nervous and Muscular Systems
- Respiratory System
- Symptom - Laboured breathing
- Eye
- Symptom - Blindness (permanent)
12. How long did the symptoms last?
>1 wk <=1 mo / > 1 sem < = 1 mois
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
Died
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
2 days after product application, the dog became lethargic. On December 25th, the dog was recumbent, possibly blind, had eye discharge. The owner declined to bring the dog to a veterinarian for financial reasons. The dog was bathed in dish soap. 24hrs later the dog was less lethargic and started eating. On December 31st, the dog deteriorated and had labored breathing. The dog died on the way to an emergency clinic on January 1st. The owner declined necropsy for personal reasons. The veterinarian who did not examine the dog did not suspect Advantage for the clinical signs and subsequent death of the dog. The veterinarian suspected possible pyometra.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here