Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-4654

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

Environment

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

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)

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PMRA Registration No. 28784      PMRA Submission No.       EPA Registration No.

Product Name: 2% STRYCHNINE LIQUID CONCENTRATE

• Active Ingredient(s)
  • STRYCHNINE

---

PMRA Registration No. 28751      PMRA Submission No.       EPA Registration No.

Product Name: 2% LIQUID STRYCHNINE CONCENTRATE

• Active Ingredient(s)
  • STRYCHNINE

---

PMRA Registration No.       PMRA Submission No.       EPA Registration No.

Product Name: Unknown

• Active Ingredient(s)
  • CHLOROPHACINONE

---

7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

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).

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

unknown

4. Number of animals affected

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Unknown

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?

Unknown / Inconnu

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

Unknown/Inconnu

16. How was the animal exposed?

Other / Autre

17. Provide any additional details about the incident

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

During the period of the 2008-09 EUR there were reports of poisoning of non-target animals from sources including the Ministry of Environment Conservation Officers, producer evaluations and the researcher conducting the RGS research projects. However details are sparse and actual causes were not determined with only a few cases associated with necropsies. Non-target species include raptor (birds), predators (badger, fox, and weasel), ungulates (antelope) and possibly dogs. It should be noted that in most cases cause of death appears most likely to be a result of anticoagulant (chlorophacinone) poisoning rather than from strychnine.

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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

Subform IV: Environment (includes plants insects and wildlife)

1. Type of organism affected

Bird - Predatory / Oiseau - De proie

2. Common name(s)

Raptors

3. Scientific name(s)

Unknown

4. Number of organisms affected

Unknown

5. Description of site where incident was observed

Fresh water

Terrestrial

Other

Salt Water

6. Check all symptoms that apply

Death

7. Describe symptoms and outcome (died, recovered, etc.).

During the period of the 2008-09 Emergency Use Registration there were reports of poisoning of non-target animals from sources including the Ministry of Environment Conservation Officers, producer evaluations and the researcher conducting the Richardson's Ground Squirrels research projects. However details are sparse and actual causes were not determined with only a few cases associated with necropsies. Non-target species include raptor (birds), predators (badger, fox, and weasel), ungulates (antelope) and possibly dogs. It should be noted that in most cases cause of death appears most likely to be a result of anticoagulant (chlorophacinone) poisoning rather than from strychnine.

8. a) Was the incident a result of (select all that apply)

Unknown

8. b) i) How many times has the product been applied this year?

Unknown

8. b) ii) What was the date of the last application?

Unknown

9. Did it rain

9. a) During application?

Unknown

9. b) Up to 3 days after application?

Unknown

10. a) Was there a buffer zone?

Unknown

10. b) What type?

10. c) What was the size of the buffer zone?

11. a) Were environmental samples collected and analysed?

Unknown

To be determined by Registrant

12. Severity classification (if there is more than one possible classification, select the most severe)

13. Please provide supplemental information here

Subform IV: Environment (includes plants insects and wildlife)

1. Type of organism affected

Mammal-Small/Mammifère-De petite taille

2. Common name(s)

Badger

3. Scientific name(s)

Unknown

4. Number of organisms affected

Unknown

5. Description of site where incident was observed

Fresh water

Terrestrial

Other

Salt Water

6. Check all symptoms that apply

Death

7. Describe symptoms and outcome (died, recovered, etc.).

During the period of the 2008-09 Emergency Use Registration there were reports of poisoning of non-target animals from sources including the Ministry of Environment Conservation Officers, producer evaluations and the researcher conducting the Richardson's Ground Squirrels research projects. However details are sparse and actual causes were not determined with only a few cases associated with necropsies. Non-target species include raptor (birds), predators (badger, fox, and weasel), ungulates (antelope) and possibly dogs. It should be noted that in most cases cause of death appears most likely to be a result of anticoagulant (chlorophacinone) poisoning rather than from strychnine.

8. a) Was the incident a result of (select all that apply)

Unknown

8. b) i) How many times has the product been applied this year?

Unknown

8. b) ii) What was the date of the last application?

Unknown

9. Did it rain

9. a) During application?

Unknown

9. b) Up to 3 days after application?

Unknown

10. a) Was there a buffer zone?

Unknown

10. b) What type?

10. c) What was the size of the buffer zone?

11. a) Were environmental samples collected and analysed?

Unknown

To be determined by Registrant

12. Severity classification (if there is more than one possible classification, select the most severe)

13. Please provide supplemental information here

Subform IV: Environment (includes plants insects and wildlife)

1. Type of organism affected

Mammal-Small/Mammifère-De petite taille

2. Common name(s)

Fox

3. Scientific name(s)

Unknown

4. Number of organisms affected

Unknown

5. Description of site where incident was observed

Fresh water

Terrestrial

Other

Salt Water

6. Check all symptoms that apply

Death

7. Describe symptoms and outcome (died, recovered, etc.).

During the period of the 2008-09 Emergency Use Registration there were reports of poisoning of non-target animals from sources including the Ministry of Environment Conservation Officers, producer evaluations and the researcher conducting the Richardson's Ground Squirrels research projects. However details are sparse and actual causes were not determined with only a few cases associated with necropsies. Non-target species include raptor (birds), predators (badger, fox, and weasel), ungulates (antelope) and possibly dogs. It should be noted that in most cases cause of death appears most likely to be a result of anticoagulant (chlorophacinone) poisoning rather than from strychnine.

8. a) Was the incident a result of (select all that apply)

Unknown

8. b) i) How many times has the product been applied this year?

Unknown

8. b) ii) What was the date of the last application?

Unknown

9. Did it rain

9. a) During application?

Unknown

9. b) Up to 3 days after application?

Unknown

10. a) Was there a buffer zone?

Unknown

10. b) What type?

10. c) What was the size of the buffer zone?

11. a) Were environmental samples collected and analysed?

Unknown

To be determined by Registrant

12. Severity classification (if there is more than one possible classification, select the most severe)

13. Please provide supplemental information here

Subform IV: Environment (includes plants insects and wildlife)

1. Type of organism affected

Mammal-Small/Mammifère-De petite taille

2. Common name(s)

Weasel

3. Scientific name(s)

Unknown

4. Number of organisms affected

Unknown

5. Description of site where incident was observed

Fresh water

Terrestrial

Other

Salt Water

6. Check all symptoms that apply

Death

7. Describe symptoms and outcome (died, recovered, etc.).

During the period of the 2008-09 Emergency Use Registration there were reports of poisoning of non-target animals from sources including the Ministry of Environment Conservation Officers, producer evaluations and the researcher conducting the Richardson's Ground Squirrels research projects. However details are sparse and actual causes were not determined with only a few cases associated with necropsies. Non-target species include raptor (birds), predators (badger, fox, and weasel), ungulates (antelope) and possibly dogs. It should be noted that in most cases cause of death appears most likely to be a result of anticoagulant (chlorophacinone) poisoning rather than from strychnine.

8. a) Was the incident a result of (select all that apply)

Unknown

8. b) i) How many times has the product been applied this year?

Unknown

8. b) ii) What was the date of the last application?

Unknown

9. Did it rain

9. a) During application?

Unknown

9. b) Up to 3 days after application?

Unknown

10. a) Was there a buffer zone?

Unknown

10. b) What type?

10. c) What was the size of the buffer zone?

11. a) Were environmental samples collected and analysed?

Unknown

To be determined by Registrant

12. Severity classification (if there is more than one possible classification, select the most severe)

13. Please provide supplemental information here

Subform IV: Environment (includes plants insects and wildlife)

1. Type of organism affected

Mammal-Large,solitary/Mammifère-Grande

2. Common name(s)

Antelope

3. Scientific name(s)

Unknown

4. Number of organisms affected

Unknown

5. Description of site where incident was observed

Fresh water

Terrestrial

Other

Salt Water

6. Check all symptoms that apply

Death

7. Describe symptoms and outcome (died, recovered, etc.).

During the period of the 2008-09 Emergency Use Registration there were reports of poisoning of non-target animals from sources including the Ministry of Environment Conservation Officers, producer evaluations and the researcher conducting the Richardson's Ground Squirrels research projects. However details are sparse and actual causes were not determined with only a few cases associated with necropsies. Non-target species include raptor (birds), predators (badger, fox, and weasel), ungulates (antelope) and possibly dogs. It should be noted that in most cases cause of death appears most likely to be a result of anticoagulant (chlorophacinone) poisoning rather than from strychnine.

8. a) Was the incident a result of (select all that apply)

Unknown

8. b) i) How many times has the product been applied this year?

Unknown

8. b) ii) What was the date of the last application?

Unknown

9. Did it rain

9. a) During application?

Unknown

9. b) Up to 3 days after application?

Unknown

10. a) Was there a buffer zone?

Unknown

10. b) What type?

10. c) What was the size of the buffer zone?

11. a) Were environmental samples collected and analysed?

Unknown

To be determined by Registrant

12. Severity classification (if there is more than one possible classification, select the most severe)

13. Please provide supplemental information here