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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-2646

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: x

City: x

Prov / State: x

Country: x

Postal Code: X

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

Domestic Animal

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.


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.


PMRA Registration No.       PMRA Submission No.       EPA Registration No.

Product Name:

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


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

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

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?


Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

German shorthair pointer

4. Number of animals affected


5. Sex


6. Age (provide a range if necessary )


7. Weight (provide a range if necessary )


8. Route(s) of exposure


9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>30 min <=2 hrs / >30 min <=2 h

11. List all symptoms


  • Nervous and Muscular Systems
    • Symptom - Seizure
  • General
    • Symptom - Anaphylactic shock

12. How long did the symptoms last?

Persisted until death

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


14. a) Was the animal hospitalized?


14. b) How long was the animal hospitalized?


Hour(s) / Heure(s)

15. Outcome of the incident

Euthanised / Euthanasie

16. How was the animal exposed?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

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

The following was reported: April 8, 2017, Out walking with dog. 7 month old German short hair pointer (name). Was walking at a friend's farm west of (city), at the south west end of (road). Approx. LSD of incident was (legal subdivision). Weather was sunny, however ground still had I to 2 feet of snow cover. Near the end of the walk, around 3:30pm, (name) went temporarily out of site. She returned within a couple minutes with a deer leg. Deer leg still had hair and meat on it. No cause for concern. 4:30pm (name) began to have seizures and go into anaphylactic shock. Resuscitate, rush to X Vet hospital. (name) was put on 5 anti-seizure medications to control seizures. By 9:30 am on April 9 we had to make the decision to let (name) go as they couldn't reduce any medications without the seizures returning. Doctors were running out of seizure medication due to the high quantity needed. They were also worried about permanent brain damage and fluid pooling in the lungs. Necropsy was completed at the X vet hospital, samples were set to the X lab services to test for canine distemper. Results came back negative. Samples sent to X veterinary diagnostic laboratory for toxicology, came back positive for STRYCHNlNE. After (name) was at the vet hospital on the evening of April 8, went back out to farm to collect deer leg and look for any more sign of deer carcass. Was able to easily track where she had gone due to the snow pack and no other parts of a deer carcass were found. Have been back to the location of poisoning numerous times since and no other parts of a carcass have been found. The friends farm we were on never has and never will use Strychnine.

To be determined by Registrant

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

Not Applicable

19. Provide supplemental information here