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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2020-0390
2. Registrant Information.
Registrant Reference Number: 2554339
Registrant Name (Full Legal Name no abbreviations): Bayer CropScience Inc.
Address: 160 QUARRY PARK BLVD. SE Suite 200
City: CALGARY
Prov / State: AB
Country: Canada
Postal Code: T2C 3G3
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
08-NOV-195. Location of incident.
Country: UNITED STATES
Prov / State: TEXAS
6. Date incident was first observed.
15-OCT-19Product 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. 432-772
Product Name: DeltaDust 5 lb
- Active Ingredient(s)
- DELTAMETHRIN
- Guarantee/concentration .05 %
- DELTAMETHRIN
PMRA Registration No. PMRA Submission No. EPA Registration No. 432-1255
Product Name: MaxForce Granular Insect Bait 25 lb
- Active Ingredient(s)
- HYDRAMETHYLNON
- Guarantee/concentration 1 %
- HYDRAMETHYLNON
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: Res. - Out Home / Rés - à l'ext.maison
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding application.To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
YesSubform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Maltese
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
16
7. Weight (provide a range if necessary )
11.00
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
<=15 min / <=15 min
10. Time between exposure and onset of symptoms
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Anorexia
- Symptom - Vomiting
- General
- Symptom - Death
12. How long did the symptoms last?
Persisted until death
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?
Unknown
15. Outcome of the incident
Died
16. How was the animal exposed?
Other / Autre
specify Defined point of exposure not evident or witnessed. Exposure based on speculation.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
11/8/2019 The following report was forwarded for documentation. Caller reports that on 10/15/2019 her lawn care company applied an unknown flea control product to her lawn. Caller was not home at the time and does not know what product was used. Caller's dog would have had access to the treated area on the day of application, but she is unsure if the product was wet or not. On 10/16/2019 caller's dog vomited a large amount and became anorexic. No additional vomiting occurred, and no home therapies were performed and the dog was not evaluated by a veterinarian. On 10/17/2019 the dog died at home. No other symptoms aside from anorexia were present at the time of death. 11/11/2019 Call back from the original caller. The lawn care company provided the name of the product, but no further details. 11/15/2019 Call back from the original caller. Caller spoke to the lawn care company again, and they did provide the names of three products.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
