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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-4976

2. Registrant Information.

Registrant Reference Number: 2016-14

Registrant Name (Full Legal Name no abbreviations): BASF

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.

15-AUG-16

5. Location of incident.

Country: UNITED STATES

Prov / State: VIRGINIA

6. Date incident was first observed.

10-AUG-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. 7969-272

Product Name: Drive XLR8 herbicide

  • Active Ingredient(s)
    • QUINCLORAC
      • Guarantee/concentration 18.92 %

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

golden retriever

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

0.2

7. Weight (provide a range if necessary )

8

lbs

8. Route(s) of exposure

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

  • General
    • Symptom - Lethargy
    • Symptom - Death
  • Respiratory System
    • Symptom - Heavy breathing
  • Gastrointestinal System
    • Symptom - Anorexia
    • Symptom - Vomiting

12. How long did the symptoms last?

>3 days <=1 wk / >3 jours <=1 sem

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

Died

16. How was the animal exposed?

Other / Autre

specify unknown if animal exposed at all

17. Provide any additional details about the incident

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

Dog brought home from breeder July31, began showing symptoms August 10, died August 18. No known exposure, but products possible were BASF Drive XLR8 herbicide, Gowan Sledgehammer herbicide or Lysol. Dog died of liver failure, pneumonia.


To be determined by Registrant

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

Death

19. Provide supplemental information here

No known exposure, doubtful likelihood