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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-5121

2. Registrant Information.

Registrant Reference Number: Rocky Mountain Poison and Drug case #5670911

Registrant Name (Full Legal Name no abbreviations): LOVELAND Products Canada, Inc.

Address: 789 Donnybrook Drive

City: Dorchester

Prov / State: Ontario

Country: Canada

Postal Code: N0L1G5

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

Domestic Animal

4. Date registrant was first informed of the incident.

23-AUG-16

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

13-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. 11889      PMRA Submission No.       EPA Registration No.

Product Name: DIAZINON 500 E

  • Active Ingredient(s)
    • DIAZINON

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: Unknown / Inconnu

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Dog was in a field earlier this week, and jumped into the drainage ditch he went for a dive, and water was coming out of his nostrils Friend washed the dog with a hose afterwards, but not shampoo Time of exposure Tuesday 8/9 @ 1400 The farmer told the dog owner they sprayed Diazinon 500 E on the field @ MN on 8/7 Believe 1/2 life is 48 hours, and concerned he was exposed at 36 hours afterwards O: today symptoms started: lethargic eating slow when walking nose is warm A: acute animal dermal, nasal and unknown if any other routes to Diazinon 500 E, syptomatic

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

Rhodesian Ridgeback

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

2

7. Weight (provide a range if necessary )

100

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

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

11. List all symptoms

System

  • Nervous and Muscular Systems
    • Symptom - Ataxia
    • Symptom - Trembling
  • General
    • Symptom - Lethargy
    • Symptom - Drowsiness
    • Specify - Drowsy

12. How long did the symptoms last?

Unknown / Inconnu

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

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

Dog was in a field earlier this week, and jumped into the drainage ditchhe went for a dive, and water was coming out of his nostrils Friend washed the dog with a hose afterwards, but not shampoo Time of exposure Tuesday 8/9 @ 1400 The farmer told the dog owner they sprayed Diazinon 500 E on the field @ MN on 8/7 Believe 1/2 life is 48 hours, and concerned he was exposed at 36 hours afterwards O: today symptoms started: lethargic eating slow when walking nose is warm A: acute animal dermal, nasal and unknown if any other routes to Diazinon 500 E, syptomatic R: warm transferred to 8003454735, case #160120054 Keep case open for returned notes


To be determined by Registrant

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

Minor

19. Provide supplemental information here