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Sécurité des produits de consommation

Déclaration d'incident

Sous-formulaire I: Renseignements généraux

1.Type de rapport.

Nouvelle déclaration d'incident

No de la demande: 2016-5127

2. Renseignements concernant le titulaire.

Numéro de référence du titulaire d'homologation: 1820721

Nom du titulaire (nom légal complet, aucune abbréviation): Bayer CropScience Inc.

Adresse: 160 QUARRY PARK BLVD. SE Suite 200

Ville: CALGARY

État: AB

Pays: Canada

Code postal /Zip: T2C 3G3

3.Choisir le (les) sous-formulaire(s) correspondant à l'incident.

Incident chez l'humain

Incident chez un animal domestique

4. Date à laquelle le titulaire d'homologation a été informé pour la première fois de l'incident.

12-MAY-16

5. Lieu de l'incident.

Pays: UNITED STATES

État: IOWA

6. Date de la première observation de l'incident.

12-MAY-16

Description du produit

7. a) Donner le nom de la matière active et, si disponibles, le numéro d'homologation et le nom du produit (incluant tous les mélanges). Si le produit n'est pas homologué, donner le numéro de la demande d'homologation.

Matière(s) active(s)

ARLA No d'homologation       ARLA No de la demande d'homologation       EPA No d'homologation. 264-1066

Nom du produit: Bayer Corvus Herbicide

  • Matière active
    • ISOXAFLUTOLE
      • Garantie/concentration 19 %
    • THIENCARBAZONE-METHYL

ARLA No d'homologation       ARLA No de la demande d'homologation       EPA No d'homologation. Inconnu

Nom du produit: Nitrogen

  • Matière active

7. b) Type de formulation.

Renseignments sur l'application

8. Est-ce que le produit a été appliqué?

Oui

9. Dose d'application.

Inconnu

10. Site d'application (choisir tout ce qui s'applique).

Site: Agricultural-Outdoor/Agricole-extérieur

Specify Type: Field adjacent to caller's property

11. Donner tout renseignement additionnel concernant l'application (comment le produit a été appliqué, la quantité utilisée, la superficie de la zone traitée, etc.)

Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding application.

À être déterminé par le titulaire

12. Selon vous, le produit a-t-il été utilisé en conformité avec le mode d'emploi de L'étiquette?

Oui

Sous-formulaire II : Incident chez l'humain (Obligation d'utiliser un formulaire séparé pour chaque personne affectée)

1. Source de la déclaration.

Professionnel de la santé

2. Renseignement démographique sur la personne affectée

Sexe: Femme

Âge: >12 <=19 yrs / >12 <=19 ans

3. Énumérez tous les symptômes, au moyen des choix suivants.

Système

  • Système respiratoire
    • Symptôme - Irritation des voies respiratoires
    • Symptôme - Respiration faible
    • Symptôme - oedème pulmonaire

4. Quelle a été la durée des symptômes?

>3 days <=1 wk / >3 jours <=1 sem

5. La personne affectée a-t-elle reçu des soins médicaux? Donner les détails à la question 13.

Inconnu

6. a) Est-ce que la personne a été hospitalisée?

Non

6. b) Pendant combien de temps?

Inconnu

7. Scénario d'exposition

Non professionnel

8. Comment l'exposition s'est-elle produite? (cocher tout ce qui s'applique)

Quelle était l'activité? Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding the activity

Dérive du pesticide à partir de la zone traitée

9.Si l'exposition s'est produite lors du traitement ou au moment du retour dans la zone traitée, de l'équipement de protection individuelle était-il porté? (cocher tout ce qui s'applique)

Aucun

10. Voie(s) d'exposition.

Inconnu

11.Durée de l'exposition?

<=15 min / <=15 min

12.Temps écoulé entre l'exposition et l'apparition des symptômes.

>8 hrs <=24 hrs / > 8 h < = 24 h

13.Donner tout détail additionnel au sujet de l'incident (p.ex. description des symptômes tels que la fréquence et la gravité, type de soins médicaux, résultats des tests médicaux, quantité de pesticide à laquelle la personne a été exposée, etc.)

5/12/2016 Caller's neighbor applied products on the field next to caller's property on 5/7/2016. Caller has a chicken coop next to that field. The day after application, some of the chickens began showing signs of difficulty breathing. Ten chickens died the morning after application, and 2 more died that evening. Caller found 2 more dead chickens the following morning. Caller went to the veterinarian to discuss chickens symptoms, and caller was sent home with Albon to administer to the chickens' water. Caller has lost a total of 23 chickens. Caller also states that a few of their dogs were running in a pasture near the field while products were being applied. The dogs may have been lethargic this week. The 2 dogs vomited the evening after application, and a large amount of grass and dog food was found in the vomitus. Caller saw 1 dog having a seizure this morning, which lasted 5 minutes before the dog recovered. The dog is still at home and has not been examined by the veterinarian. Caller realized today that the animals' water had been outside during application, and changed the water today. Caller also reports that chores were done after the product was sprayed, but did not indicate if this occurred on the day of application or the day after. Caller's daughter has asthma, and has had respiratory irritation since the day of application. Daughter has been using a nebulizer, inhaler, and taking Prednisone. Daughter complained that it is difficult to breath today. 5/13/2016 Call back to the original caller. Caller took 10 dead chickens for necropsy today and approximately 20 more were put down. Caller's daughter is doing okay, but her lungs fill with fluid at night and caller has to give her a nebulizer treatment. The family cat was also found today after laying in the weeds for a couple of days. The cat is refusing food, and they intend to take cat to the veterinarian. The dog is no longer seizing. 5/17/2016 Call back to the original caller. The cat was brought to the veterinarian on 5/13/2016. The cat was at the clinic for 3 hours and was given subcutaneous fluids, Convenia injection, Cerenia subcutaneous, and sent home. The cat is much better, but not back to normal. The dogs were bathed at home and are back to normal. The dogs were not treated by a veterinarian. A pesticide reporter has been at the home today taking pictures, samples, and getting affidavits from the neighbor.

À être déterminé par le titulaire

14. Classification selon la gravité.

Modérée

15. Donner des renseignements additionnels ici.

Sous-formulaire III : Animal domestique

1. Source de la déclaration

Professionnel de la santé

2.Type d'animal touché

Dog / Chien

3. Race

Labrador Retriever

4. Nombre d'animaux touchés

1

5. Sexe:

Femme

6. Âge (fournir un ordre de grandeur si nécessaire)

1.50

7. Poids (fournir un ordre de grandeur si nécessaire)

53.00

lbs

8. Voie(s) d'exposition:

Inconnu

9. Durée de l'exposition?

<=15 min / <=15 min

10. Temps écoulé entre l'exposition et l'apparition des symptômes

>3 days <=1 wk / >3 jours <=1 sem

11. Énumérer tous les symptômes

Système

  • Système gastro-intestinal
    • Symptôme - Vomit
  • General
    • Symptôme - Lethargie
  • Systèmes nerveux et musculaire
    • Symptôme - Crise

12. Quelle a été la durée des symptômes?

<=30 min / <=30 min

13. Des soins médicaux ont-ils été prodigués? Donner les détails à la question 17.

Non

14. a) Est-ce que l'animal a-t-il été hospitalisé?

Non

14. b) Combien de temps l'animal était-il hospitalisé?

Inconnu

15. Issue de l'incident

Fully Recovered / Complètement rétabli

16. De quelle manière l'animal a-t-il été exposé?

Other / Autre

préciser Defined point of exposure not evident or witnessed. Exposure based on speculation.

17. Donnez tout détail additionnel au sujet de l'incident

(p.ex. description des symptômes tels que la fréquence et la gravité

5/12/2016 Caller's neighbor applied products on the field next to caller's property on 5/7/2016. Caller has a chicken coop next to that field. The day after application, some of the chickens began showing signs of difficulty breathing. Ten chickens died the morning after application, and 2 more died that evening. Caller found 2 more dead chickens the following morning. Caller went to the veterinarian to discuss chickens symptoms, and caller was sent home with Albon to administer to the chickens' water. Caller has lost a total of 23 chickens. Caller also states that a few of their dogs were running in a pasture near the field while products were being applied. The dogs may have been lethargic this week. The 2 dogs vomited the evening after application, and a large amount of grass and dog food was found in the vomitus. Caller saw 1 dog having a seizure this morning, which lasted 5 minutes before the dog recovered. The dog is still at home and has not been examined by the veterinarian. Caller realized today that the animals' water had been outside during application, and changed the water today. Caller also reports that chores were done after the product was sprayed, but did not indicate if this occurred on the day of application or the day after. Caller's daughter has asthma, and has had respiratory irritation since the day of application. Daughter has been using a nebulizer, inhaler, and taking Prednisone. Daughter complained that it is difficult to breath today. 5/13/2016 Call back to the original caller. Caller took 10 dead chickens for necropsy today and approximately 20 more were put down. Caller's daughter is doing okay, but her lungs fill with fluid at night and caller has to give her a nebulizer treatment. The family cat was also found today after laying in the weeds for a couple of days. The cat is refusing food, and they intend to take cat to the veterinarian. The dog is no longer seizing. 5/17/2016 Call back to the original caller. The cat was brought to the veterinarian on 5/13/2016. The cat was at the clinic for 3 hours and was given subcutaneous fluids, Convenia injection, Cerenia subcutaneous, and sent home. The cat is much better, but not back to normal. The dogs were bathed at home and are back to normal. The dogs were not treated by a veterinarian. A pesticide reporter has been at the home today taking pictures, samples, and getting affidavits from the neighbor.


À être déterminé par le titulaire

Classification selon la gravité (s'il y a plus d'une catégorie possible, veuillez choisir la plus grave)

Modérée

19. Donner des renseignements additionnels ici

Sous-formulaire III : Animal domestique

1. Source de la déclaration

Professionnel de la santé

2.Type d'animal touché

Bird / Oiseau

3. Race

Chicken

4. Nombre d'animaux touchés

23

5. Sexe:

Femme

6. Âge (fournir un ordre de grandeur si nécessaire)

Inconnu

7. Poids (fournir un ordre de grandeur si nécessaire)

Inconnu

8. Voie(s) d'exposition:

Inconnu

9. Durée de l'exposition?

<=15 min / <=15 min

10. Temps écoulé entre l'exposition et l'apparition des symptômes

>8 hrs <=24 hrs / > 8 h < = 24 h

11. Énumérer tous les symptômes

Système

  • General
    • Symptôme - Mort
  • Système respiratoire
    • Symptôme - Irritation des voies respiratoires

12. Quelle a été la durée des symptômes?

Persisted until death

13. Des soins médicaux ont-ils été prodigués? Donner les détails à la question 17.

Oui

14. a) Est-ce que l'animal a-t-il été hospitalisé?

Non

14. b) Combien de temps l'animal était-il hospitalisé?

Inconnu

15. Issue de l'incident

Mort

16. De quelle manière l'animal a-t-il été exposé?

Other / Autre

préciser Defined point of exposure not evident or witnessed. Exposure based on speculation.

17. Donnez tout détail additionnel au sujet de l'incident

(p.ex. description des symptômes tels que la fréquence et la gravité

5/12/2016 Caller's neighbor applied products on the field next to caller's property on 5/7/2016. Caller has a chicken coop next to that field. The day after application, some of the chickens began showing signs of difficulty breathing. Ten chickens died the morning after application, and 2 more died that evening. Caller found 2 more dead chickens the following morning. Caller went to the veterinarian to discuss chickens symptoms, and caller was sent home with Albon to administer to the chickens' water. Caller has lost a total of 23 chickens. Caller also states that a few of their dogs were running in a pasture near the field while products were being applied. The dogs may have been lethargic this week. The 2 dogs vomited the evening after application, and a large amount of grass and dog food was found in the vomitus. Caller saw 1 dog having a seizure this morning, which lasted 5 minutes before the dog recovered. The dog is still at home and has not been examined by the veterinarian. Caller realized today that the animals' water had been outside during application, and changed the water today. Caller also reports that chores were done after the product was sprayed, but did not indicate if this occurred on the day of application or the day after. Caller's daughter has asthma, and has had respiratory irritation since the day of application. Daughter has been using a nebulizer, inhaler, and taking Prednisone. Daughter complained that it is difficult to breath today. 5/13/2016 Call back to the original caller. Caller took 10 dead chickens for necropsy today and approximately 20 more were put down. Caller's daughter is doing okay, but her lungs fill with fluid at night and caller has to give her a nebulizer treatment. The family cat was also found today after laying in the weeds for a couple of days. The cat is refusing food, and they intend to take cat to the veterinarian. The dog is no longer seizing. 5/17/2016 Call back to the original caller. The cat was brought to the veterinarian on 5/13/2016. The cat was at the clinic for 3 hours and was given subcutaneous fluids, Convenia injection, Cerenia subcutaneous, and sent home. The cat is much better, but not back to normal. The dogs were bathed at home and are back to normal. The dogs were not treated by a veterinarian. A pesticide reporter has been at the home today taking pictures, samples, and getting affidavits from the neighbor.


À être déterminé par le titulaire

Classification selon la gravité (s'il y a plus d'une catégorie possible, veuillez choisir la plus grave)

Mort

19. Donner des renseignements additionnels ici

Sous-formulaire III : Animal domestique

1. Source de la déclaration

Professionnel de la santé

2.Type d'animal touché

Dog / Chien

3. Race

Labrador Retriever

4. Nombre d'animaux touchés

1

5. Sexe:

Inconnu

6. Âge (fournir un ordre de grandeur si nécessaire)

Inconnu

7. Poids (fournir un ordre de grandeur si nécessaire)

Inconnu

8. Voie(s) d'exposition:

Inconnu

9. Durée de l'exposition?

<=15 min / <=15 min

10. Temps écoulé entre l'exposition et l'apparition des symptômes

>3 days <=1 wk / >3 jours <=1 sem

11. Énumérer tous les symptômes

Système

  • Système gastro-intestinal
    • Symptôme - Vomit
  • General
    • Symptôme - Lethargie

12. Quelle a été la durée des symptômes?

Unknown / Inconnu

13. Des soins médicaux ont-ils été prodigués? Donner les détails à la question 17.

Non

14. a) Est-ce que l'animal a-t-il été hospitalisé?

Non

14. b) Combien de temps l'animal était-il hospitalisé?

Inconnu

15. Issue de l'incident

Fully Recovered / Complètement rétabli

16. De quelle manière l'animal a-t-il été exposé?

Other / Autre

préciser Defined point of exposure not evident or witnessed. Exposure based on speculation.

17. Donnez tout détail additionnel au sujet de l'incident

(p.ex. description des symptômes tels que la fréquence et la gravité

5/12/2016 Caller's neighbor applied products on the field next to caller's property on 5/7/2016. Caller has a chicken coop next to that field. The day after application, some of the chickens began showing signs of difficulty breathing. Ten chickens died the morning after application, and 2 more died that evening. Caller found 2 more dead chickens the following morning. Caller went to the veterinarian to discuss chickens symptoms, and caller was sent home with Albon to administer to the chickens' water. Caller has lost a total of 23 chickens. Caller also states that a few of their dogs were running in a pasture near the field while products were being applied. The dogs may have been lethargic this week. The 2 dogs vomited the evening after application, and a large amount of grass and dog food was found in the vomitus. Caller saw 1 dog having a seizure this morning, which lasted 5 minutes before the dog recovered. The dog is still at home and has not been examined by the veterinarian. Caller realized today that the animals' water had been outside during application, and changed the water today. Caller also reports that chores were done after the product was sprayed, but did not indicate if this occurred on the day of application or the day after. Caller's daughter has asthma, and has had respiratory irritation since the day of application. Daughter has been using a nebulizer, inhaler, and taking Prednisone. Daughter complained that it is difficult to breath today. 5/13/2016 Call back to the original caller. Caller took 10 dead chickens for necropsy today and approximately 20 more were put down. Caller's daughter is doing okay, but her lungs fill with fluid at night and caller has to give her a nebulizer treatment. The family cat was also found today after laying in the weeds for a couple of days. The cat is refusing food, and they intend to take cat to the veterinarian. The dog is no longer seizing. 5/17/2016 Call back to the original caller. The cat was brought to the veterinarian on 5/13/2016. The cat was at the clinic for 3 hours and was given subcutaneous fluids, Convenia injection, Cerenia subcutaneous, and sent home. The cat is much better, but not back to normal. The dogs were bathed at home and are back to normal. The dogs were not treated by a veterinarian. A pesticide reporter has been at the home today taking pictures, samples, and getting affidavits from the neighbor.


À être déterminé par le titulaire

Classification selon la gravité (s'il y a plus d'une catégorie possible, veuillez choisir la plus grave)

Mineure

19. Donner des renseignements additionnels ici

Sous-formulaire III : Animal domestique

1. Source de la déclaration

Professionnel de la santé

2.Type d'animal touché

Cat / Chat

3. Race

Unknown

4. Nombre d'animaux touchés

1

5. Sexe:

Femme

6. Âge (fournir un ordre de grandeur si nécessaire)

Inconnu

7. Poids (fournir un ordre de grandeur si nécessaire)

Inconnu

8. Voie(s) d'exposition:

Inconnu

9. Durée de l'exposition?

Unknown / Inconnu

10. Temps écoulé entre l'exposition et l'apparition des symptômes

Unknown / Inconnu

11. Énumérer tous les symptômes

Système

  • Système gastro-intestinal
    • Symptôme - Anorexie

12. Quelle a été la durée des symptômes?

Unknown / Inconnu

13. Des soins médicaux ont-ils été prodigués? Donner les détails à la question 17.

Oui

14. a) Est-ce que l'animal a-t-il été hospitalisé?

Non

14. b) Combien de temps l'animal était-il hospitalisé?

Inconnu

15. Issue de l'incident

Unknown/Inconnu

16. De quelle manière l'animal a-t-il été exposé?

Other / Autre

préciser Defined point of exposure not evident or witnessed. Exposure based on speculation.

17. Donnez tout détail additionnel au sujet de l'incident

(p.ex. description des symptômes tels que la fréquence et la gravité

5/12/2016 Caller's neighbor applied products on the field next to caller's property on 5/7/2016. Caller has a chicken coop next to that field. The day after application, some of the chickens began showing signs of difficulty breathing. Ten chickens died the morning after application, and 2 more died that evening. Caller found 2 more dead chickens the following morning. Caller went to the veterinarian to discuss chickens symptoms, and caller was sent home with Albon to administer to the chickens' water. Caller has lost a total of 23 chickens. Caller also states that a few of their dogs were running in a pasture near the field while products were being applied. The dogs may have been lethargic this week. The 2 dogs vomited the evening after application, and a large amount of grass and dog food was found in the vomitus. Caller saw 1 dog having a seizure this morning, which lasted 5 minutes before the dog recovered. The dog is still at home and has not been examined by the veterinarian. Caller realized today that the animals' water had been outside during application, and changed the water today. Caller also reports that chores were done after the product was sprayed, but did not indicate if this occurred on the day of application or the day after. Caller's daughter has asthma, and has had respiratory irritation since the day of application. Daughter has been using a nebulizer, inhaler, and taking Prednisone. Daughter complained that it is difficult to breath today. 5/13/2016 Call back to the original caller. Caller took 10 dead chickens for necropsy today and approximately 20 more were put down. Caller's daughter is doing okay, but her lungs fill with fluid at night and caller has to give her a nebulizer treatment. The family cat was also found today after laying in the weeds for a couple of days. The cat is refusing food, and they intend to take cat to the veterinarian. The dog is no longer seizing. 5/17/2016 Call back to the original caller. The cat was brought to the veterinarian on 5/13/2016. The cat was at the clinic for 3 hours and was given subcutaneous fluids, Convenia injection, Cerenia subcutaneous, and sent home. The cat is much better, but not back to normal. The dogs were bathed at home and are back to normal. The dogs were not treated by a veterinarian. A pesticide reporter has been at the home today taking pictures, samples, and getting affidavits from the neighbor.


À être déterminé par le titulaire

Classification selon la gravité (s'il y a plus d'une catégorie possible, veuillez choisir la plus grave)

Mineure

19. Donner des renseignements additionnels ici