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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-2162

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-29867323

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: CALIFORNIA

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. 8119-13

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 / Rés - à 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?

No

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Dalmatian

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

11

7. Weight (provide a range if necessary )

70

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

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

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

  • Respiratory System
    • Symptom - Tachypnea
  • Nervous and Muscular Systems
    • Symptom - Difficulty getting up

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

Fully Recovered / Complètement rétabli

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

1-29867323- The reporter, a pet owner, indicates his animals were exposed to a pesticide product containing the active ingredient metaldehyde. The reporter indicated he had applied the product to his yard the day of his initial contact and had observed his eleven year old male seventy pound Dalmatian dog (Subform III,#1) ingesting the product. The animal was reported to be breathing rapidly and unable to rise. The pet owner was advised to seek immediate veterinary assistance. On follow up the pet owner indicated the animal was treated and released fully recovered by the veterinarian. He did not describe the treatment. He added at this point that his three year male five pound Chihuahua dog (Subform III, #2) had later the day he initially contacted the registrant developed signs of ataxia and seizures. The animal died under the veterinarians care two days later. 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

Chihuahua

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

3

7. Weight (provide a range if necessary )

5.5

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

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

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

  • Nervous and Muscular Systems
    • Symptom - Ataxia
    • Symptom - Seizure
  • General
    • 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

1-29867323- The reporter, a pet owner, indicates his animals were exposed to a pesticide product containing the active ingredient metaldehyde. The reporter indicated he had applied the product to his yard the day of his initial contact and had observed his eleven year old male seventy pound Dalmatian dog (Subform III,#1) ingesting the product. The animal was reported to be breathing rapidly and unable to rise. The pet owner was advised to seek immediate veterinary assistance. On follow up the pet owner indicated the animal was treated and released fully recovered by the veterinarian. He did not describe the treatment. He added at this point that his three year male five pound Chihuahua dog (Subform III, #2) had later the day he initially contacted the registrant developed signs of ataxia and seizures. The animal died under the veterinarians care two days later. 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