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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-4845

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.


4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

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.       PMRA Submission No.       EPA Registration No.

Product Name:

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


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?


Subform IV: Environment (includes plants insects and wildlife)

1. Type of organism affected


2. Common name(s)

Grizzly bear

3. Scientific name(s)


4. Number of organisms affected


5. Description of site where incident was observed

Fresh water



Salt Water

6. Check all symptoms that apply


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

A two to three year old bear was found dead on Mr.(name) property at the (location) quarter (Section #), Township #, Range #, West of the (name). The bear was found to have strychnine in the carcass. F&W officers (name and name), investigated the incident and assumed Richardson's Ground Squirrels poisoning was the source of strychnine. No purchases of two per cent LSC were made in the area in 2010. RTU baits may have been used nearby and reportedly were used in 2010 by neighbours. A suspected Richardson's Ground Squirrels bait station found was not the usual type and not a recommended tamper resistant station. In fact, a tire with a plywood bottom was found in the are awhich makes a poor bait station for Richardson's Ground Squirrels. The described tire is a common container for salt blocks by ranchers. In my estimation, the F&W report shows a myriad of scenarios happending that indicate something other than an accidental non-target poisoning of a bear. Neighbours had complained about a sow and three yearling cubs in the area. A neighbour had shot the sow, two of her yearlings had died, and the third was found poisoned with Richardson's Ground Squirrels baiting. Something was not logical and I interviewed the (name). They have never purchased strychnine from our two per cent LSC program. Unless more direct evidence is found, I doubt very much the bear succumbed to a RTU strychning baiting program for Richardson's Ground Squirrels. A lab report on the stomach contents of the bear would help to check for grain as a carrier of the strychnine and the concentration of the strychnine found. The report may not be definitive enough as the bear was badly decomposed.

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


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


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


9. Did it rain

9. a) During application?


9. b) Up to 3 days after application?


10. a) Was there a buffer zone?


10. b) What type?

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

11. a) Were environmental samples collected and analysed?


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