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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-2110

2. Registrant Information.

Registrant Reference Number: NEU 29535 7Jun18 1

Registrant Name (Full Legal Name no abbreviations): W. Neudorff GmbH KG

Address: #11-6782 Veyaness Road

City: Saanichton

Prov / State: BC

Country: Canada

Postal Code: V8M 2C2

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

Domestic Animal

4. Date registrant was first informed of the incident.

04-JUN-18

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

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. 29535      PMRA Submission No.       EPA Registration No.

Product Name: Fiesta Lawn Weed Killer

  • Active Ingredient(s)
    • IRON (PRESENT AS FEHEDTA)

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).

The product had been applied by a professional; there was a posting on the lawn stating Fiesta Lawn Weed Killer. The lawn was outside a condo building at x.

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

standard poodle

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

4.5

7. Weight (provide a range if necessary )

46

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

  • Gastrointestinal System
    • Symptom - Bloody diarrhea

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.

Unknown

14. a) Was the animal hospitalized?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Fully Recovered / Complètement rétabli

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 walking on treated grass and sniffing. It is possible that the dog ingested some grass or weeds, but the owner didn't witness it.


To be determined by Registrant

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

Minor

19. Provide supplemental information here