Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2024-1848

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: QUEBEC

6. Date incident was first observed.

16-APR-24

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. 24175      PMRA Submission No.       EPA Registration No.

Product Name: DRAGNET FT EMULSIFIABLE CONCENTRATE INSECTICIDE.

• Active Ingredient(s)
  • PERMETHRIN

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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: Res. - In Home / Rés. - à l'int. maison

Préciser le type: Kitchen cabinets and floorboards

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Utilisation du produit Dragnet par une entreprise de services d'extermination contactée pour traiter une problématique de pyrales indiennes dans mes armoires de cuisine. Cette même entreprise a également installer des appâts le même jour pour infiltration de souris. Une enquête est en cours par Santé Canada. Vous pouvez vous référer à (NOM), Agent de conformité et d'application de la loi, Programme de la conformité des pesticides pour de plus amples renseignements dans ce dossier.

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

Australian Shepherd

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

5

7. Weight (provide a range if necessary )

15.7

kg

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

• Skin
  • Symptom - Itchy skin

• General
  • Symptom - Restlessness
  • Symptom - Discomfort

• Skin
  • Symptom - Red skin
  • Specify - Significant redness over the entire surface of the abdomen and under the joints of the front legs

• Gastrointestinal System
  • Symptom - Vomiting
  • Specify - Vomiting of yellowish and foamy liquid
  • Symptom - Bloody vomit
  • Specify - Vomiting of clear, wine-red liquid

• General
  • Symptom - Lethargy

• Gastrointestinal System
  • Symptom - Anorexia

• General
  • Symptom - Adipsia

• Gastrointestinal System
  • Symptom - Melena
  • Symptom - Bloody diarrhea

• Nervous and Muscular Systems
  • Symptom - Muscle tremors

• Skin
  • Symptom - Irritated skin

• Eye
  • Symptom - Watery eye
  • Symptom - Red eye

• Gastrointestinal System
  • Symptom - Bloody vomit
  • Specify - Pink and wine-red vomit
  • Symptom - Diarrhea
  • Specify - Mucoid Diarrhea containing fresh blood

• Skin
  • Symptom - Erythema

• Gastrointestinal System
  • Symptom - Loss of appetite
  • Symptom - Bloody stool
  • Specify - Very dark/black loose stools with fresh blood

• General
  • Symptom - Other
  • Specify - Very difficult to administer oral medications
  • Symptom - Dehydration

• Gastrointestinal System
  • Symptom - Other
  • Specify - Abdomen: Slightly tense palpation in depth
  • Symptom - Other
  • Specify - Slightly irregular rectal mucosa
  • Symptom - Other
  • Specify - Empty anal sacs
  • Symptom - Other
  • Specify - Secondary gastroenteritis
  • Symptom - Other
  • Specify - Erosions/ulcerations
  • Symptom - Other
  • Specify - Esophagitis

• Nervous and Muscular Systems
  • Symptom - Depression
  • Symptom - Anxiety
  • Specify - Stressed
  • Symptom - Recumbent
  • Specify - Remains laying down

• General
  • Symptom - Other
  • Specify - Apathetic

• Eye
  • Symptom - Red eye
  • Specify - Eyelid erythema
  • Symptom - Discharge eye
  • Specify - Slight serous discharge

• General
  • Symptom - Discomfort
  • Specify - Tense, discomfort on abdominal palpation

• Gastrointestinal System
  • Symptom - Vomiting
  • Specify - Liquid, saliva, and foam vomiting
  • Symptom - Diarrhea
  • Symptom - Vomiting

• Nervous and Muscular Systems
  • Symptom - Agitation

• General
  • Symptom - Other
  • Specify - Sticky mucous membranes

• Skin
  • Symptom - Pruritus
  • Symptom - Dermatitis

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.

Yes

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.

17. Provide any additional details about the incident

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

J'ai dû consulter pour ma chienne qui présentait les symptômes suivants (en ordre d'apparition ou d'observation des manifestation cliniques), quelques heures après avoir exposé à un pesticide probablement à base de perméthrines, soit le Dragnet: - Prurit important - Agitation et inconfort - Rougeur importante au niveau de toute la surface de l'abdomen et sous les articulations des pattes d'avant -vomissements répétés de liquide d'aspect jaunâtre et mousseux -vomissement de liquide clair et d'aspect rouge vin -État léthargique -Anorexie et refus de s'hydrater - Méléna possible - Diarrhées avec présence de sang ¿ Tremblements

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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