Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2019-5729
2. Registrant Information.
Registrant Reference Number: 30922
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.
16-SEP-19
5. Location of incident.
Country: CANADA
Prov / State: ALBERTA
6. Date incident was first observed.
11-SEP-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. Unknown
Product Name: k9 advantix II pipette size unknown
- Active Ingredient(s)
- IMIDACLOPRID
- PERMETHRIN
- PYRIPROXYFEN
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: 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).
On 11-Sep-2019, a 5 year old Dachshund in good condition with no concomitant medical conditions was administered one K 9 ADVANTIX II (unknown dose- please note medium dog is selected above as it is a mandatory field), by Veterinarian. The product was used according to label (unknown).
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
Dachshund (Standard)-Kurzhaar
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
5
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Skin
9. What was the length of exposure?
>3 days <=1 wk / >3 jours <=1 sem
10. Time between exposure and onset of symptoms
>2 hrs <=8 hrs / > 2 h < = 8 h
11. List all symptoms
System
- Nervous and Muscular Systems
- Symptom - Muscle twitching
- Skin
- Symptom - Itchy skin
- Symptom - Erythema
- Specify - Ear Reddening
- Nervous and Muscular Systems
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?
No
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Unknown/Inconnu
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
3 hours after application the dog developed a muscle twitch of the left ear. The dog then became itchy on the left side. The dog was taken to an emergency clinic where it was found the dog had ear reddening and the dog was precribed Surolan (miconazole nitrate, polymyxin B sulfate, prednisolone acetate suspension). The dog remained uncomfortable and was then given a dose of benadryl (diphenhydramine).
On 16 Sept 2019 the dog became wobbly. The outcome is unknown.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
19. Provide supplemental information here