Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-1885
2. Registrant Information.
Registrant Reference Number: 040617
Registrant Name (Full Legal Name no abbreviations): Liphatech, Inc.
Address: 3600 W Elm Street
City: Milwaukee
Prov / State: Wisconsin
Country: USA
Postal Code: 53217
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
03-FEB-17
5. Location of incident.
Country: CANADA
Prov / State: NOVA SCOTIA
6. Date incident was first observed.
02-FEB-17
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. 20257
PMRA Submission No.
EPA Registration No.
Product Name: BootHill Pellets Place Packs
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
43
Units: g
10. Site pesticide was applied to (select all that apply).
Site: Animal / Usage sur un animal domestique
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
One pellet place pack was set next to the wall in an animal barn (housing chickens) with a piece of plywood on top of it
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
No
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Bird - Poultry / Oiseau - Volaille
3. Breed
Laying Hen
4. Number of animals affected
5
5. Sex
Female
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?
>8 hrs <= 24 hrs / >8 h <= 24 h
10. Time between exposure and onset of symptoms
>3 days <=1 wk / >3 jours <=1 sem
11. List all symptoms
System
- Nervous and Muscular Systems
- Symptom - Disorientation
- Specify - clumsy
- General
- Symptom - Lethargy
- Specify - lazy
12. How long did the symptoms last?
>24 hrs <=3 days / >24 h <=3 jours
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
Unknown/Inconnu
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
160 chickens had access to 1 place pack on 2/3/17, on 2/7/17 it was reported that some chickens were acting "clumsy and lazy". Farmer called vet, but there was no treatment plan as of 2/7/17. Liphatech advised the farmer that anticoagulant rodenticides last in tissues for many months and they do pass from the hen to the egg. The farmer and his vet contacted local authorities for guidance on selling his eggs.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Bird - Poultry / Oiseau - Volaille
3. Breed
Laying Hen
4. Number of animals affected
1
5. Sex
Female
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?
>8 hrs <= 24 hrs / >8 h <= 24 h
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
160 chickens had access to 1 place pack on 2/3/17, on 2/7/17 it was reported that one chicken had died.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here