Domestic Animal Incident

To submit form, send to

Mailing address:
Health Canada
Pest Management Regulatory Agency
2720 Riverside Drive
Ottawa, Ontario
A.L. 6606D2
K1A 0K9
Attention: Pesticide Incident Reporting Program

Phone: 1-800-267-6315 within Canada
1-613-736-3799 outside of Canada (Long distance charges apply)

Instructions

• It is important to provide as much information as possible. The more information collected, the better understanding the Pest Management Regulatory Agency (PMRA) will have of the incident.
• Do not include information in the report form that could lead to the identification of an individual. Examples include doctor's names, hospital names, etc. This information will not be added to our records.
• If there is not enough space provided for you to answer the question, you may attach a separate sheet with the text on it.

How will the information you are about to report be used by the PMRA?

Pesticides are tested and evaluated for environmental and health risks before they are registered by the PMRA. However, some adverse effects may not become evident until the product is used under "real-life" circumstances. The information you are about to report will provide the PMRA with valuable data regarding potential risks to humans from the use of pesticides in "real-life" circumstances.

Information provided by the public and by professionals is added to the PMRA database on pesticides. The database will be regularly searched for any type of pattern related to a specific pesticide. If the result of a search indicates that there is a trend, such as multiple incidents for a particular pesticide, the PMRA will evaluate the information in conjunction with scientific literature. If evaluation of this information identifies a safety issue, appropriate action will be taken. Such action could range from minor label changes to discontinuation of the product.

In order for the information you provide to be useful, it is necessary to be as specific as possible, particularly with regards to the type of pesticide and the effect(s) experienced.

Domestic Animal Incident

Use a separate form for each animal affected. If an incident involves multiple animals of the same type with the same symptoms, a single form can be used (see Question 6)

1. Provide location where the incident occurred (see Confidentiality Statement).

• City / Locality:
• Province:

2. Who is reporting this incident?

• Animal owner
• Veterinary professional
• Witness
• Other (describe)

3. Date incident occurred (dd/mm/yyyy):

4. If known, provide the product registration number and product name of the pesticide, both of which are on the product label. If not known, list the active ingredients.

Help
Registration number examples:

• Registration No. 23756 Pest Control Products Act
• REG. NO. 55555 P.C.P ACT

Product name example:

• Weed Be Gone

Active ingredient example:

• glyphosate

5. If known, describe the application of the pesticide. Include the amount of pesticide applied (application rate), the site that the pesticide was applied to and the method of application.

Help
Application rate examples:

• 10 ml of pesticide
• 1 flea collar
• 1 10 oz can
• 1 cc of pesticide
• 12 g ai/ha

Site examples:

• living room carpet
• dog
• front lawn
• strawberries

Method of application examples:

• spot-on treatment
• flea shampoo
• hose-end sprayer
• bait station
• aerosol

6. What type of animal was affected? (Choose only one per form)

• Dog
• Sheep
• Cat
• Bird
• Cow
• Fish
• Poultry
• Pig
• Horse
• Other (describe):

What is the breed of animal?
Number of animals affected:
Help
Examples of breeds:

• golden retriever
• siamese
• mixed
• parrot

7. Describe all symptoms. Include the length of time the symptom(s) lasted, the severity of the symptom(s), and how often the symptom(s) occurred. Also describe any medical treatment that the animal received, including medication prescribed or test results.
Help
Examples:

• Lethargy that lasted for 3 days. Dog was taken to a veterinarian and medication Y was prescribed.
• Vomiting approximately every hour for 5 hours. Called the poison control centre; no treatment was recommended.
• Tremors for 3 hours

8. How was the animal exposed to the pesticide? Include the amount of pesticide the animal was exposed to, and how long or how often the animal was exposed to it.
Help
Examples:

• Dog was treated with pesticide (e.g. flea collar, spot-on treatment)
• Cat was not treated, but licked dog that had been treated for fleas.
• Dog ate 3 ant traps.
• Children accidentally sprayed cat in the face with bear spray.

9. What was exposed?

• Skin
• Eye
• Oral
• Respiratory (breathing)
• Unknown

10. What was the outcome of the incident?

• Full recovery
• Residual effects
• Death
• Euthanasia (Put down)
• Unknown

11. Has this incident been reported to the manufacturer?

• Yes
• No
• Unknown

If so, when was it reported (dd/mm/yyyy)?

What was the name of the manufacturer?
Help
The name, address and telephone number of the manufacturer is listed on the label.

12. Additional information can be provided in the space below, or on a separate sheet. Help
Important: do not include personal information such as names or addresses. (see Confidentiality Statement)

Confidentiality Statement: Any information related to the identity of persons will be protected as per the Privacy Act. Any unsolicited personal information will be destroyed.