Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2020-2172
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.
04-APR-20
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. 27884
PMRA Submission No.
EPA Registration No.
Product Name: Par 3
- Active Ingredient(s)
- 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)
- DICAMBA (PRESENT AS ACID, ESTER, SALTS)
- MECOPROP-P (PRESENT AS DIMETHYLAMINE SALT)
7. b) Type of formulation.
Liquid
Application Information
8. Product was applied?
Unknown
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).
The following was reported: My neighbour was illegally supplied with par 3 and sprayed not only my lawn with out my knowledge but also some of my annual plants started at school. My dog vommitted, diarrhea and was lethargic and weak. My exposure is unknown to the plants and also my second dogs exposure is unknown(he is a therapy dog). I attend the university of x xx campus as a horticulture student. I have taken a certification and safety course on pesticides. I reported the initial incident to one of my teachers (name) and asked if she thought my plants had been sprayed with a pesticide. Her initial thoughts were that it would be hard for a public citizen to obtain this level of pesticide, which is true. I went upon my business and didn't think much of it but upon noticing absolutely no weeds in my yard or my neighbours I knew something had been sprayed. On a later date I later witnessed my neighbour (name) walking into his Garage with a jug of something, so I questioned what it was and he told me it was a class 2 pesticide PAR 3 and I said to him I knew my plants were sprayed and he laughed as I didn't know what to do with the situation at the time I continued questioning and asked where he got the pesticide and notified me that he received it from (name) who is my landlord. I than reported that information to law clerk Who will only be named through direct communication and she directed my question to my lawyer.
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 - Vomiting
- Symptom - Diarrhea
- General
- Symptom - Weakness
- Symptom - Lethargy
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.
specify Oral exposure was reported
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
The following was reported: My dog vommitted, diarrhea and was lethargic and weak.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Not Applicable
19. Provide supplemental information here