Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2023-1105
2. Registrant Information.
Registrant Reference Number: 6624239
Registrant Name (Full Legal Name no abbreviations): Premier Tech Limited
Address: 1, avenue Premier
City: Riviere-du-Loup
Prov / State: QC
Country: Canada
Postal Code: G5R 6C1
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
09-DEC-22
5. Location of incident.
Country: CANADA
Prov / State: ALBERTA
6. Date incident was first observed.
09-DEC-22
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. 21936
PMRA Submission No.
EPA Registration No.
Product Name: Wilson AntOut Ant Killer Dust
- Active Ingredient(s)
- SILICON DIOXIDE (PRESENT AS 100% DIATOMACEOUS EARTH) - FRESH WATER FOSSILS
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
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).
Product was applied in July 2022.
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
German Shorthair Pointer
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
0.33
7. Weight (provide a range if necessary )
15
lbs
8. Route(s) of exposure
Respiratory
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 - Muscle weakness
- Symptom - Ataxia
- General
- Symptom - Loss of balance
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Unknown
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?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here
Caller stated that his 4-month dog's balance was off and hind legs were weak that morning on their walk. Product was applied approximately 6 months earlier, in July. Caller that his dog might have sniffed the area where the product had been applied.