Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-3267

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: x

City: x

Prov / State: x

Country: x

Postal Code: X

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

Domestic Animal

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

10-JUL-11

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. 28751      PMRA Submission No.       EPA Registration No.

Product Name: 2% LIQUID STRYCHNINE CONCENTRATE

• Active Ingredient(s)
  • STRYCHNINE

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

10

Other Units: gms

10. Site pesticide was applied to (select all that apply).

Site: Agricultural-Outdoor/Agricole-extérieur

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

5-15 gms of treated oat bait placed down RGS holes in a 150 acre field of late seeded barley intended for greenfeed harvest.

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

Other

2. Type of animal affected

Dog / Chien

3. Breed

Husky

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

1

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

Dog found dead and was taken to local Vet for analysis. Dog was sent to University of (name). for lab analysis. Stomach contents of dog contained RGS carcass remains and strychnine residue. Dog consumed a poisoned Richardson Ground Squirrel. University Lab report is available. Dog owner stated the dog did not leave her property. The adjacent property owner was poisoning RGS on his property. He followed all the label requirements except he placed the baid out 4 days after the registration deadline. He claimed due to wet conditions he could not get the bait out earlier. He noticed a large number of RGS poisoned as compared to previous control efforts. He picked up and destroyed all dead carcasses he could find. RGS bait was placed out July 4,2011. Details of names, addresses property owners and investigators are available from RSD (city, province, address,phone number) or (county) Supervisor of Agricultural Services (phone number, address, city, province)

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To be determined by Registrant

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

Not Applicable

19. Provide supplemental information here