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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-125. Location of incident.
Country: UNITED STATES
Prov / State: CALIFORNIA
6. Date incident was first observed.
22-APR-12Product 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 %
- METALDEHYDE
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
