Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2021-5836

2. Registrant Information.

Registrant Reference Number: X

Registrant Name (Full Legal Name no abbreviations): X

Address: X

City: X

Prov / State: X

Country: X

Postal Code: X

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

Packaging Failure

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

25-OCT-21

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)

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PMRA Registration No. 31513      PMRA Submission No.       EPA Registration No.

Product Name: VICTOR V FAST-KILL BRAND DISPOSABLE BAIT STATION

• Active Ingredient(s)
  • DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
    • Guarantee/concentration .005 %

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7. b) Type of formulation.

Bait

Application Information

8. Product was applied?

Yes

9. Application Rate.

56

Units: g

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

Site: Unknown / Inconnu

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

The present design uses two vertical tabs to hold the rodenticide in position. I used two traps over a period of two days and in both situations, the bait had been removed by the rodent and deposited on the carpet in two separate rooms. A black plastic container 5cm x 3.7 cm x 15 cm. Poison label. keep out of the reach of children. Contains a 28 g bait block containing the active ingredient Diphacinone 0.005%.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

Subform VI: Packaging Failure

1. What is the type of packaging that failed?

Bait station / Point d'appât

2. Did packaging failure occur during?

Use of Product

specify I used two traps over a period of two days and in both situations, the bait had been removed by the rodent and deposited on the carpet in two separate rooms. What is happening is when the rodent gnaws on the bait it is reduced in size to the point where it is no longer contained by the tabs and then carried off by the rodent. In my case deposited on the carpet.

3. Did packaging failure result in?

potential exposure

4. Describe how the packaging failed and the surrounding circumstances, including a description of the potential injury or exposure.

What is happening is when the rodent gnaws on the bait it is reduced in size to the point where it is no longer contained by the tabs and then carried off by the rodent. In my case deposited on the carpet. My concern is this poisonous bait exposes small children and pets to a very dangerous situation. Small children are designed to pop small objects into their mouths. Ergo the hazard. Pets who are naturally curious may do likewise.

For Registrant use only

5. Provide supplemental information here.