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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2837

2. Registrant Information.

Registrant Reference Number: CDN Incident Report 071015

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

Address: 3600 West Elm Street

City: Milwaukee

Prov / State: Wisconsin

Country: United States

Postal Code: 53209

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

Domestic Animal

4. Date registrant was first informed of the incident.

15-JUN-15

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

Unknown

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. 29545      PMRA Submission No.       EPA Registration No.

Product Name: Rozol RTU Field Rodent Bait

  • Active Ingredient(s)
    • CHLOROPHACINONE

7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Unknown / Inconnu

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

Applied over spingtime in bait stations

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

Cat / Chat

3. Breed

mixed

4. Number of animals affected

2

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?

Other / Autre

specify Secondary poisoning

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

Secondary poisoning reported as cause. Multiple barn cats died from eating poisoned animals caller referred to as gophers. Number of cats affected is unknown; question 4 lists 2 animals affected because the form does not accept text in this field and since the caller reported multiple cats it is only known that more than one cat was affected.


To be determined by Registrant

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

Death

19. Provide supplemental information here