Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-4428

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.

11-JUL-23

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)

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PMRA Registration No. 29535      PMRA Submission No.       EPA Registration No.

Product Name: FIESTA LAWN WEED KILLER

• Active Ingredient(s)
  • IRON (PRESENT AS FEHEDTA)

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7. b) Type of formulation.

Liquid

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).

Neighbors had a [Company] sign up on the front lawn. Asked if they had sprayed the backyard as well. Lawn in the backyard is now completely black except for the weeds they were trying to kill. It was raining on Tuesday.

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

Cat / Chat

3. Breed

UNKNOWN

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• Nervous and Muscular Systems
  • Symptom - Recumbent

• Eye
  • Symptom - Other
  • Specify - Eyes completely rolled over

• Liver
  • Symptom - Hepatic failure

• Gastrointestinal System
  • Symptom - Other
  • Specify - Gallbladder failure

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

Euthanised / Euthanasie

16. How was the animal exposed?

Other / Autre

specify UNKNOWN

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

We found him curled up in a ball beside the adjoining fence under one of our evergreens. He couldn't stand up, his eyes were completely rolled over. We picked him up and put him inside to watch over him. Liver and gall bladder failure. The cat went from a happy active cat on that Tuesday to a dead one Tuesdsy night. We put him down on the following Friday.

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To be determined by Registrant

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

Not Applicable

19. Provide supplemental information here