Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-7513
2. Registrant Information.
Registrant Reference Number: 2073689
Registrant Name (Full Legal Name no abbreviations): Bayer CropScience Inc.
Address: 160 QUARRY PARK BLVD. SE Suite 200
City: CALGARY
Prov / State: AB
Country: Canada
Postal Code: T2C 3G3
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
12-JUL-17
5. Location of incident.
Country: UNITED STATES
Prov / State: ILLINOIS
6. Date incident was first observed.
08-JUL-17
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. 72155-5
Product Name: All In One Weed Killer for Lawns (Concentrate)
- Active Ingredient(s)
- 2,4-D (PRESENT AS ACID)
- Guarantee/concentration .12 %
- DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, OR SODIUM SALT)
- Guarantee/concentration .02 %
- MECOPROP P-ISOMER (PRESENT AS ACID)
- Guarantee/concentration .06 %
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. - Out Home / Rés - à l'ext.maison
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding application.
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Yes
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Yorkshire Terrier (Yorkie)
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
8
7. Weight (provide a range if necessary )
4.00
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
<=15 min / <=15 min
10. Time between exposure and onset of symptoms
>2 hrs <=8 hrs / > 2 h < = 8 h
11. List all symptoms
System
- Respiratory System
- Symptom - Choking
- Symptom - Rapid breathing
- Symptom - Shortness of breath
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?
Unknown
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
7/12/2017 Caller mixed product with water in a pump sprayer and sprayed a small area of the yard on 7/8/2017. Caller is not sure what ration of product and water he used. Caller did not allow the dogs in yard until later in the day on 7/9/2017, and the the area was dried. Around midnight on 7/9/2017 one dog began having difficulty breathing. She was breathing rapidly and making a choking type noise. Caller was unable to find anywhere to take the pate at that time of night, so he took her to his primary care veterinarian the next morning. As they were arriving at the clinic, the dog died. The veterinarian was not able to tell him what caused the pet to die. No diagnostics or necropsy were performed. The dog was previously healthy and not on any medications.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here