Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-6218

2. Registrant Information.

Registrant Reference Number: 2023-CA-000262

Registrant Name (Full Legal Name no abbreviations): Evergreen Animal Health, LLC

Address: 22655 Centennial Road

City: Gretna

Prov / State: Nebraska

Country: USA

Postal Code: 68028

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

10-JUL-23

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

10-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. 33790      PMRA Submission No.       EPA Registration No.

Product Name: Parapet K9 Praventa 360 for Large Dogs 11-25kg

• Active Ingredient(s)
  • IMIDACLOPRID
  • PERMETHRIN
  • PYRIPROXYFEN

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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).

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?

No

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Other / Autre

specify Goat

3. Breed

Unknown

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

3

7. Weight (provide a range if necessary )

11.34

kg

8. Route(s) of exposure

Skin

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>30 min <=2 hrs / >30 min <=2 h

11. List all symptoms

System

• General
  • Symptom - Abnormal behaviour

• Gastrointestinal System
  • Symptom - Nausea

• General
  • Symptom - Other
  • Specify - Staring

12. How long did the symptoms last?

Unknown / Inconnu

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?

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

On 10-Jul-2023, a 3 year old, approximately 11.34 kilogram, male goat of unknown breed, in unknown condition, with no known concomitant medical conditions, was administered a partial tube of Parapet K9 Praventa 360 for Large Dogs 11-25kg (Imidacloprid, Permethrin, Pyriproxyfen) topically by the animal owner. The goat may have ingested some of the product from the application site but this was not witnessed. This was an extra label use of the product due to species (goat), and application of a partial tube of the product. Approximately 2 hours post application the goat developed nausea and staring into space (abnormal behaviour). No treatments were performed and the clinical signs continued. Bathing the goat using liquid dish soap and monitoring for new or worsening signs was recommended. No further information was received.

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To be determined by Registrant

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

Minor

19. Provide supplemental information here

The information contained in this report is based on self-reported statements provided to the registrant during telephone interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and cannot form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews.