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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-7023

2. Registrant Information.

Registrant Reference Number: 6079429

Registrant Name (Full Legal Name no abbreviations): PremierTech Ltd.

Address: 1, avenue Premier

City: Riviere-du-Loup

Prov / State: QC

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.

19-JUN-19

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

14-JUN-19

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 Predator Wilsarin Rat & Mouse Killer

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

PMRA Registration No. 18992      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Wilsarin Rat and Mouse Bait Pellets

  • Active Ingredient(s)
    • BROMADIOLONE

7. b) Type of formulation.

Application Information

8. Product was applied?

No

9. Application Rate.

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

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

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

not known

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

0.8

7. Weight (provide a range if necessary )

7

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>3 days <=1 wk / >3 jours <=1 sem

11. List all symptoms

System

  • Gastrointestinal System
    • Symptom - Melena

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?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

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

Caller stated that his dog may have ingested the product 5 days ago but is not sure. About a tsp appeared to be missing. Symptoms observed a day ago. Pet owner told to have vet call if there were any questions/concerns.


To be determined by Registrant

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

Moderate

19. Provide supplemental information here

Caller unsure what product he had at home. Did not bring packaging with him to clinic but was going to ask mother to check at home. Caller was provided with the Reg. No. 18992 to look for on the package since other possibility, Reg. No. 30535, would not be expected to create symptom described. Unknown if symptoms are related to exposure. Recent sterilization and pain medication.