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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-2201

2. Registrant Information.

Registrant Reference Number: 062309

Registrant Name (Full Legal Name no abbreviations): Liphatech, Inc.

Address: 3600 West Elm Street

City: Milwaukee

Prov / State: WI

Country: USA

Postal Code: 53209

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

Domestic Animal

4. Date registrant was first informed of the incident.

17-JAN-09

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

6. Date incident was first observed.

17-JAN-09

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.       PMRA Submission No.       EPA Registration No. 7173-218

Product Name: Generation Mini Block

  • Active Ingredient(s)
    • CHLOROPHACINONE
    • DIFETHIALONE
      • Guarantee/concentration .0025 %

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. - In Home / Rés. - à l'int. maison

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

Blocks were place in OR around a residential site a pest control company. The blocks were placed in bait stations. Dog died some time after the placement and the customer claims rodenticide poisoning although no tests were done and no veterinarian's report was provided.

To be determined by Registrant

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

Yes

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Unknown

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

  • General
    • Symptom - Death

12. How long did the symptoms last?

Persisted until death

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

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

No medical tests were done and no veterinarian was seen, as far as we know. Customer made an unsupported claim to pest control agency that dog died from rodenticide poisoning and pest control agency contacted our salesperson for more information on symptoms, signs and prevention of such poisonings.


To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

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

lab mix

4. Number of animals affected

2

5. Sex

Male

6. Age (provide a range if necessary )

4

7. Weight (provide a range if necessary )

65

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

>3 days <=1 wk / >3 jours <=1 sem

10. Time between exposure and onset of symptoms

>3 days <=1 wk / >3 jours <=1 sem

11. List all symptoms

System

  • Blood
    • Symptom - Bleeding
  • General
    • Symptom - Death

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.

No

14. a) Was the animal hospitalized?

No

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

Rozol Pellets were applied to an orchard as is usually done every year. Guard dogs are used to keep deer away from orchard. When one of the dogs was found in his house, dead, with blood from mouth and nose, the other dogs were checked. The second dog was found listless in a field. Both dogs were brought to the veterinarian immediately. The listless dog was given Vitamin K1 immediately but, later that day the owner and doctor determined that the dog needed to be put down. Tissue samples were taken from this second dog. The doctor confirmed to the owner that Rozol was the cause of death but we were not given the test results. These are available through Dr. (name), (name) Hospital, (address) .,(city) (state) phone #


To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here

One animal died and the other was euthanized as stated above.