Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-2853

2. Registrant Information.

Registrant Reference Number: 2016-3

Registrant Name (Full Legal Name no abbreviations): BASF canada

Address: 100 Milverton

City: Mississauga

Prov / State: ON

Country: Canada

Postal Code: L5R4H1

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

17-MAY-16

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

17-MAY-16

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)

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PMRA Registration No. 30685      PMRA Submission No.       EPA Registration No.

Product Name: Insure Cereal Fungicide

• Active Ingredient(s)
  • METALAXYL
  • PYRACLOSTROBIN
  • TRITICONAZOLE

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7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

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

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Lab

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

8

7. Weight (provide a range if necessary )

28

kg

8. Route(s) of exposure

Skin

Oral

9. What was the length of exposure?

<=15 min / <=15 min

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• Nervous and Muscular Systems
  • Symptom - Trembling

• General
  • Symptom - Lethargy

• Skin
  • Symptom - Erythema

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.

Yes

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?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

Dog got under sprayer May 10, was dripped on, unknown dilution, became lethargic soon after. Seen by DVM May 13 but only mild lethargy, lethargy progressed over subsequent days-DVM noted trembling and red blotches on skin. IV fluids provided.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Minor

19. Provide supplemental information here

Low likelihood. Dog may also have been exposed to Raxil PRO and/or CRUISER Vibrance quattro