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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-2161

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-29997522

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.

03-MAY-12

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

6. Date incident was first observed.

03-MAY-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. 8119-13

Product Name: Corrys Slug Snail Pellets MP

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

7. b) Type of formulation.

Bait

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 / Rs - l'ext.maison

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

mixed breed

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

10

7. Weight (provide a range if necessary )

15

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

Unknown / Inconnu

11. List all symptoms

System

  • Nervous and Muscular Systems
    • Symptom - Ataxia
    • Symptom - Muscle tremors

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

1-29997522- The reporter, a pet owner, indicated his animals had been exposed to a pesticide containing the active ingredient metaldehyde. The pet owner stated he had applied the product to his lawn earlier in the day. He had allowed his two dogs access to the application area during the course of the day. He assumes the animals ingested the product but did not observe exposure. He returned home at lunch to find his eleven month female eight pound mixed breed dog dead (Sub form III #2). He reports his ten year female fifteen pound mixed breed dog (Sub form III, #1) was at the veterinarian at the point of his initial contact. He had noted ataxia and tremor in the animal. The pet owner was offered the standards of care associated with domestic animal ingestion. The caller was not reached for follow up. No further information is available.


To be determined by Registrant

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

Moderate

19. Provide supplemental information here

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Mixed breed

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

0.9

7. Weight (provide a range if necessary )

8

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

Unknown / Inconnu

11. List all symptoms

System

  • General
    • Symptom - Death

12. How long did the symptoms last?

Persisted until death

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

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

1-29997522- The reporter, a pet owner, indicated his animals had been exposed to a pesticide containing the active ingredient metaldehyde. The pet owner stated he had applied the product to his lawn earlier in the day. He had allowed his two dogs access to the application area during the course of the day. He assumes the animals ingested the product but did not observe exposure. He returned home at lunch to find his eleven month female eight pound mixed breed dog dead (Sub form III #2). He reports his ten year female fifteen pound mixed breed dog (Sub form III, #1) was at the veterinarian at the point of his initial contact. He had noted ataxia and tremor in the animal. The pet owner was offered the standards of care associated with domestic animal ingestion. The caller was not reached for follow up. 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