Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-2256
2. Registrant Information.
Registrant Reference Number: A160075275
Registrant Name (Full Legal Name no abbreviations): Dow AgroSciences Canada Inc.
Address: 2400, 215-2nd Street S.W.
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.
26-MAY-16
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
26-MAY-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. 29752
PMRA Submission No.
EPA Registration No.
Product Name: ClearView Herbicide
- Active Ingredient(s)
- AMINOPYRALID
- METSULFURON-METHYL
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
Medical Professional
2. Type of animal affected
Dog / Chien
3. Breed
Airedale Terrier Mix
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
8
7. Weight (provide a range if necessary )
55
lbs
8. Route(s) of exposure
Oral
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
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
The owner's husband was walking the pet in a park when he saw the pet starting to chew on leaves and grass that may have been treated with the product. The pet vomited once. The vomit was white foam with a few pieces of kibble in it.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here