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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-3513

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: ONTARIO

6. Date incident was first observed.

22-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.       PMRA Submission No.       EPA Registration No.

Product Name: UNKNOWN MOTHBALL

  • Active Ingredient(s)
    • NAPHTHALENE

7. b) Type of formulation.

Other (specify)

pieces of broken mothballs

Application Information

8. Product was applied?

Yes

9. Application Rate.

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

Site: Res. - Out Home / Rés - à l'ext.maison

Préciser le type: front lawn

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

The following was reported: This morning, neighbour intentionally scattered broken mothballs along the length of our front lawn, from the sidewalk to back yard (approximately 25 ft). The front lawn is used by our black lab as her play area and to do her business. Our dog went out to do her business on the lawn, inspected and sniffed at them, potentially ingesting some of the pieces. I removed the mothballs from lawn. Neighbour scattered larger pieces of mothballs along the lawn a second time and within an hour or two of me having removed them. Because the mothballs are so close to the sidewalk, we are concerned about the well-being of other dogs being walked or roaming cats in the neighbourhood. The air has stunk of mothballs the entire day because of the humidity.

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

Labrador

4. Number of animals affected

1

5. Sex

Female

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 - Bad breath
    • Specify - smelled like mothballs

12. How long did the symptoms last?

Unknown / Inconnu

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

Yes

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: Dog's breath smelled like mothballs and we were concerned she may have ingested some of the pieces intentionally scattered on lawn by neighbour. Taken to vet within 30 minutes for induced vomiting to ensure our dog had not ingested mothballs.


To be determined by Registrant

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

Not Applicable

19. Provide supplemental information here