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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-0789

2. Registrant Information.

Registrant Reference Number: 2018-1

Registrant Name (Full Legal Name no abbreviations): BASF Canada

Address: 100 Milverton Dr

City: Mississauag

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.

16-FEB-18

5. Location of incident.

Country: UNITED STATES

Prov / State: NEVADA

6. Date incident was first observed.

Unknown

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. 241-392

Product Name: Phantom

  • Active Ingredient(s)
    • CHLORFENAPYR

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).

Applied by Orkin Dec 29,2017. In February, Orkin contacted regarding bird, caller said that Orkin had treated again at end of January-this is incorrect according to Orkin, only treatment, 1x was Dec 29th.

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

Other

2. Type of animal affected

Bird / Oiseau

3. Breed

unknown breed

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

20

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Respiratory

9. What was the length of exposure?

>1 mo <= 6 mos / > 1 mois < = 6 mois

10. Time between exposure and onset of symptoms

>1 mo <=2 mos / > 1 mois < = 2 mois

11. List all symptoms

System

  • General
    • Symptom - Edema
    • Symptom - Death

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

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

Any symptoms and death were approx 1 month after PCO-applied treatment


To be determined by Registrant

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

Death

19. Provide supplemental information here

Unlikely due to chlorfenapyr, over 1 month since recorded treatment.