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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-1705

2. Registrant Information.

Registrant Reference Number: 6012191

Registrant Name (Full Legal Name no abbreviations): Premier Tech Ltd.

Address: 1 avenue Premier,

City: Riviere-du-Loup,

Prov / State: Quebec

Country: Canada

Postal Code: G5R 6C1

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

Domestic Animal

4. Date registrant was first informed of the incident.

03-JAN-19

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

09-DEC-18

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. 30535      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Wilsarin Rat And Mouse Killer

  • Active Ingredient(s)
    • CELLULOSE (FROM POWDERED CORN COBS)

7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Res. - Out Home / Rés - à l'ext.maison

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

product was applied out in the garage

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

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

American Pit Bull

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

0.25

7. Weight (provide a range if necessary )

19

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>24 hrs <=3 days / >24 h <=3 jours

11. List all symptoms

System

  • Gastrointestinal System
    • Symptom - Loss of appetite
  • Nervous and Muscular Systems
    • Symptom - Depression

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

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

Pet got into the garage on Friday and was sniffing around, the boyfriend saw him in the garage near a place pac of the rodenticide, they are not sure if he consumed any or if he was just being nosey, WCS they think he ate a pellet or 2, the rats did rip open the pac. There are other pacs in the garage but they are placed behind objects where the pet cannot get to. They noticed the pet acting depressed later that night, he was not interested in food last night or this morning. First time exposure, there is a cat in the house but it did not go anywhere near the garage. The caller was advised that this product is not a toxic risk. At most, mild and self-limiting GI upset may occur. I would not expect these signs, especially for this duration. We would expect an increase in thirst and maybe GI upset within the first 12-24 hours but since the pet is still not acting normal, take him into the DVM to be assessed.


To be determined by Registrant

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

Minor

19. Provide supplemental information here

The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified.