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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2008-4634
2. Registrant Information.
Registrant Reference Number: 1972056
Registrant Name (Full Legal Name no abbreviations): Sure-Gro Inc.
Address: 150 Savannah Oaks Dr.
City: Brantford
Prov / State: Ontario
Country: Canada
Postal Code: N3V 1E7
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
12-JUL-085. Location of incident.
Country: CANADA
Prov / State: NEW BRUNSWICK
6. Date incident was first observed.
14-JUN-08Product 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. 27492 PMRA Submission No. EPA Registration No.
Product Name: Wilson Riddex Bloks Rat and Mouse Bait
- Active Ingredient(s)
- DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)
7. b) Type of formulation.
Application Information
8. Product was applied?
Unknown
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
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?
Unknown
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Shih Tzu
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
1
7. Weight (provide a range if necessary )
12
lbs
8. Route(s) of exposure
Oral
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>30 min <=2 hrs / >30 min <=2 h
11. List all symptoms
System
- General
- Symptom - Lethargy
- Gastrointestinal System
- Symptom - Anorexia
12. How long did the symptoms last?
>24 hrs <=3 days / >24 h <=3 jours
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
Unknown/Inconnu
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
The caller indicated that her husband witnessed their dog Maggie eat part of one of the Riddex blocks yesterday. Caller's husband has just brought Maggie to the veterinarian. The animal began acting lethargic yesterday about one hour after ingesting the product. The operator who fielded the call advised the animal owner that if the bait was first ingested was yesterday afternoon, not likely that the bait has anything to do with lethargy today. It normally takes several days to use up the stored clotting factors. A few days later a message was left by the animal owners that the dog has been placed on vitamin K1 and was wondering if the Vit K1 would make her dog inappetant. The owner did state that it was hot the day the dog did not eat. Also found out that the owner is giving an oral Vit K solution of 1ml SID. The owner gave the operator the RDVMS number. A call was placed to the clinic to find out what the dose of the solution is. (on June 27, 2008 at 12:45 PM). Suggestion was made to up the pets Vit K1 dose to 1ml BID. Owner should monitor the dog closely and be careful with dog due to the incorrect dosing. Would highly recommend that the owner have a PT time drawn on the pet 48 hours post the last dose of Vit K1. Outcome unknown
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
