Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2016-2909
2. Registrant Information.
Registrant Reference Number: SC1598892
Registrant Name (Full Legal Name no abbreviations): Dow AgroSciences Canada Inc.
Address: 2400, 215-2nd Street SW
City: Alberta
Prov / State: Calgary
Country: Canada
Postal Code: T2P 1M4
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
11-FEB-16
5. Location of incident.
Country: UNITED STATES
Prov / State: KANSAS
6. Date incident was first observed.
26-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.
PMRA Submission No.
EPA Registration No. 62719-40
Product Name: Garlon 4
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
Medical Professional
2. Type of animal affected
Dog / Chien
3. Breed
Bull Mastiff
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
4
7. Weight (provide a range if necessary )
150
lbs
8. Route(s) of exposure
Oral
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 - Other
- Specify - Gastointestinal-Hematemesis/UGI Bleed
- Blood
- Symptom - Other
- Specify - Heme/Hepatic-Cytopenia (non-specific dell decline)
- Gastrointestinal System
- Symptom - Other
- Specify - Splenic lesions
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?
No
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
16. How was the animal exposed?
Other / Autre
specify that product was sprayed around dog's kennel and feels as though any time it rained, product was washed into dog's kennel.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
The product was applied around the caller's home on April 23, 2015. Approximately 4.5 months later, on September 3, 2015, her dog passed away shortly after showing signs of a twisted stomach (according to a DVM who had examined the dog).
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here