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)
PMRA Registration No. 29535
PMRA Submission No.
EPA Registration No.
Product Name: FIESTA LAWN WEED KILLER
- Active Ingredient(s)
- IRON (PRESENT AS FEHEDTA)
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
- 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.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Not Applicable
19. Provide supplemental information here