Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-3657

2. Registrant Information.

Registrant Reference Number: 2018CK021

Registrant Name (Full Legal Name no abbreviations): Bayer inc

Address: 2920 Matheson Blvd

City: Mississaugua

Prov / State: ON

Country: Canada

Postal Code: L4W 5R6

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

Domestic Animal

4. Date registrant was first informed of the incident.

09-MAY-18

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

01-MAY-18

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. 29777      PMRA Submission No.       EPA Registration No.

Product Name: K9advantixII small dog

• Active Ingredient(s)
  • IMIDACLOPRID
  • PERMETHRIN
  • PYRIPROXYFEN

---

7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

.4

Units: mL

10. Site pesticide was applied to (select all that apply).

Site: Animal / Usage sur un animal domestique

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

4.5kg 6yr yorkshire terrier of unknown sex was treated with 1 tube of k9 advantix II on may 1st.

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

Medical Professional

2. Type of animal affected

Dog / Chien

3. Breed

Yorkshire Terrier

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

6

7. Weight (provide a range if necessary )

4.5

kg

8. Route(s) of exposure

Skin

9. What was the length of exposure?

>1 wk <=1 mo / > 1 sem < = 1 mois

10. Time between exposure and onset of symptoms

<=30 min / <=30 min

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Diarrhea

• Respiratory System
  • Symptom - Panting

• General
  • Symptom - Vocalizing
  • Symptom - Adipsia
  • Symptom - Lethargy

• Gastrointestinal System
  • Symptom - Anorexia

12. How long did the symptoms last?

>3 days <=1 wk / >3 jours <=1 sem

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

Fully Recovered / Complètement rétabli

16. How was the animal exposed?

Treatment / Traitement

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

immediately after application, the dog was panting, vocalising, refused to move, eating and drinking less, soft bowel movement. The dog was examined by a veterinarian. CBC/chem/T4 was normal. No treatment was provided. the pet was recovered on may 5th

---

To be determined by Registrant

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

Minor

19. Provide supplemental information here

B - Possible Reported vocalisation and soft bowel movement are unspecific signs. However, vocalisation may be a consequence of the uncomfortable feeling caused by the applied product. Systemic disorders may be associated with reported digestive disorder. Panting is not expected with appropriate topical product use. It may rather be a behavioural reaction to product sensation than a sign of respiratory illness. Considering short time to onset, a product connection cannot be excluded and is deemed to be possible.