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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-6364

2. Registrant Information.

Registrant Reference Number: CDN Incident Report 082616

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

Address: 3600 West Elm Street

City: Milwaukee

Prov / State: Wisconsin

Country: United States

Postal Code: 53221

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

Domestic Animal

4. Date registrant was first informed of the incident.


5. Location of incident.


Prov / State: CALIFORNIA

6. Date incident was first observed.


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.


PMRA Registration No. 26618      PMRA Submission No.       EPA Registration No. 7173-218

Product Name: Generation Mini Blocks

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

7. b) Type of formulation.


Application Information

8. Product was applied?


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?


Subform III: Domestic Animal Incident Report

1. Source of Report

Medical Professional

2. Type of animal affected

Dog / Chien

3. Breed

German Shorthair

4. Number of animals affected


5. Sex


6. Age (provide a range if necessary )


7. Weight (provide a range if necessary )



8. Route(s) of exposure


9. What was the length of exposure?

>15 min <=2 hrs / >15 min <=2 h

10. Time between exposure and onset of symptoms

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

11. List all symptoms


  • Gastrointestinal System
    • Symptom - Loss of appetite
  • General
    • Symptom - Lethargy

12. How long did the symptoms last?

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

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


14. a) Was the animal hospitalized?


14. b) How long was the animal hospitalized?

15. Outcome of the incident


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 snatched one block (20 grams) out of owner's hand as it was being placed into a station. Owner immediately gave Hydrogen Peroxide and dog vomited but re-ingested it immediately. Vet induced emesis, initial injection 25mg Vitamin K1, sent home with 50 mg orally 2x / day for 7 days, then 2.5 mg / day for 5 days.

To be determined by Registrant

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


19. Provide supplemental information here

Called vet back on Sept 6 (Day 11 post-exposure) to check on status; vet called owner and was told dog had died that morning after exhibiting symptoms of lethargy and not eating for several days.