Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2016-3428
2. Registrant Information.
Registrant Reference Number: 2016-7
Registrant Name (Full Legal Name no abbreviations): BASF Canada
Address: 100 Milverton
City: Mississauga
Prov / State: ON
Country: Canada
Postal Code: L5R 4H1
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
15-JUN-16
5. Location of incident.
Country: UNITED STATES
Prov / State: PENNSYLVANIA
6. Date incident was first observed.
27-MAR-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)
PMRA Registration No.
PMRA Submission No.
EPA Registration No. 241-392
Product Name: Phantom pressurized insecticide
7. b) Type of formulation.
Other (specify)
aerosol pressurized
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
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).
Applied by PCO
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
welsh corgi
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
10
7. Weight (provide a range if necessary )
34
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>2 hrs <=8 hrs / > 2 h < = 8 h
11. List all symptoms
System
- Nervous and Muscular Systems
- Gastrointestinal System
- Symptom - Abnormal tongue colour
- Nervous and Muscular Systems
- Symptom - Difficulty walking
- Specify - limping
12. How long did the symptoms last?
Persisted until death
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?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Owners left animal out on deck during app by PCO. 2 hours post-app, nnoted dog limping on hind leg. Found dead next morning with black tongue showing
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here