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
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
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.