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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-1866

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-29866443

Registrant Name (Full Legal Name no abbreviations): Matson, LLC

Address: 45620 S. E. North Bend Way P.O. Box 1820

City: North Bend

Prov / State: Washington

Country: USA

Postal Code: 98045

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

Domestic Animal

4. Date registrant was first informed of the incident.

22-APR-12

5. Location of incident.

Country: UNITED STATES

Prov / State: OREGON

6. Date incident was first observed.

22-APR-12

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.       PMRA Submission No.       EPA Registration No. 8119-11-59144

Product Name: Eliminator Snail Slug Bait II

  • Active Ingredient(s)
    • METALDEHYDE
      • Guarantee/concentration 3.25 %

7. b) Type of formulation.

Bait

Application Information

8. Product was applied?

Unknown

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

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

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

Dachshund

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

12

7. Weight (provide a range if necessary )

20

lbs

8. Route(s) of exposure

Oral

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

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

11. List all symptoms

System

  • Respiratory System
    • Symptom - Difficulty Breathing
    • Symptom - Tachypnea
  • General
    • Symptom - Lethargy
    • Symptom - Death

12. How long did the symptoms last?

Persisted until death

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

Died

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

1-29866443- The reporter, a pet owner indicated his animal may have been exposed to a pesticide containing the active ingredient metaldehyde. The pet owner stated his twelve year female twenty pound Dachshund may have ingested the product the day prior to the initial contact. The pet owner did not describe a discreet exposure incident. It is unknown if the animal had access to an application site or the stock of the product. The pet hd demonstrated the signs of difficulty breathing, lethargy, and rapid breathing the morning of the initial contact. The pet owner was advised the time line seen was not consistent with ingestion exposures in domestic animals but that the animal should immediately be seen by a veterinarian. On follow up ne day later the pet owner indicated his animal had died at the veterinarians office. The pet owner stated the veterinarian had stated the animal had signs consistent with congestive heart failure not exposure to the product. No further information is available.


To be determined by Registrant

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

Death

19. Provide supplemental information here