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