Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2016-4519
2. Registrant Information.
Registrant Reference Number: ProPharma Group case #: 1-44532657
Registrant Name (Full Legal Name no abbreviations): Syngenta Canada Inc.
Address: 140 Research Lane, Research Park
City: Guelph
Prov / State: Ontario
Country: Canada
Postal Code: N1G4Z3
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
20-JUN-16
5. Location of incident.
Country: CANADA
Prov / State: QUEBEC
6. Date incident was first observed.
19-JUN-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. 26980
PMRA Submission No.
EPA Registration No.
Product Name: Vanquish Herbicide
- Active Ingredient(s)
- DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, OR SODIUM SALT)
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. - 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).
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
Mixed
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
3.5
7. Weight (provide a range if necessary )
12
lbs
8. Route(s) of exposure
Skin
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 - Vomiting
- Symptom - Diarrhea
- Symptom - Anorexia
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
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1-44532657 - The reporter, a pet owner, indicated that his dog may have been exposed to a pesticide with the active ingredient Dicamba (present as acid, amine salt, ester, or sodium salt). Two days before initial contact with the registrant, the reporter indicated that his 3.5-year-old, 12-pound, male, mixed breed dog had contact with a lawn sprayed with the product. One day before initial contact with the registrant, the dog developed anorexia, vomiting, and diarrhea. The reporter was advised that contact with the wet product may cause mild gastrointestinal irritation and veterinary care should be sought if the symptoms do not improve. A follow-up call was made two days after initial contact with the registrant, but the reporter could not be reached. No additional information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here