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Consumer Product Safety

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

  • Active Ingredient(s)
    • BROMADIOLONE

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

  • General
    • Symptom - Death

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