Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2019-3459
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: QUEBEC
6. Date incident was first observed.
16-JUL-19
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. 26687
PMRA Submission No.
EPA Registration No.
Product Name: AEROKURE ANT TRAP
7. b) Type of formulation.
Bait
Application Information
8. Product was applied?
Yes
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
Site: Res. - In Home / Rés. - à l'int. maison
Préciser le type: inside garage
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
The following was reported/Ce qui suit a été rapporté: Mon conjoint avait disposé une trappe à fourmis dans le garage et notre chien l'a
carrément dévorée.
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
unknown
4. Number of animals affected
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Oral
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 - Salivating excessively
- Symptom - Nausea
- Symptom - Other
- Specify - borborygmi
- Symptom - Vomiting
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
Unknown/Inconnu
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/Ce qui suit a été rapporté: Amorphe, salive abondante, nausées, ventre très bruyant, vomissements
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Not Applicable
19. Provide supplemental information here