Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-4903

2. Registrant Information.

Registrant Reference Number: Prosar 1-20451498

Registrant Name (Full Legal Name no abbreviations): Whitmire Micro-Gen Research Laboratories, Inc.

Address: 3568 Tree Court Industrial Boulevard

City: St. Louis

Prov / State: Missouri

Country: USA

Postal Code: 63122

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

Domestic Animal

4. Date registrant was first informed of the incident.

17-OCT-09

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

17-OCT-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)

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PMRA Registration No. 27897      PMRA Submission No.       EPA Registration No.

Product Name: Advance 360A Dual Choice Ant Bait Stations CANADA

• Active Ingredient(s)
  • ABAMECTIN

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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

Miniature Poodle

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

8

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

Unknown / Inconnu

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Vomiting

12. How long did the symptoms last?

>8 hrs <=24 hrs / > 8 h < = 24 h

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

Fully Recovered / Complètement rétabli

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

1-20451498: A reporter (dog owner) called on 10/17/2009 to report the exposure of her dog to an ant bait containing the active ingredient Abamectin. According to the reporter, the dog ingested a small amount of product 6 hours prior to the report and had vomited once. The dog had eaten since the episode of vomiting and appeared fine. The reporter was advised that the product has a low level of toxicity and is not expected to result in significant adverse effects following small ingestions. Minor, transient gastrointestinal upset may occur. A recommendation was made to replace any lost fluids and consult a veterinarian if signs persist. On follow up, the reporter stated that the dog vomited once more on 10/18/2009. No further vomiting occurred after that. No further information was obtained.

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To be determined by Registrant

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

Minor

19. Provide supplemental information here