Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-7036

2. Registrant Information.

Registrant Reference Number: 6096780

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.

01-AUG-19

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

25-JUL-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)

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PMRA Registration No. 31803      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Predator Mouse Killer Station Pre-Filled

• Active Ingredient(s)
  • CHLOROPHACINONE

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7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

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

Female

6. Age (provide a range if necessary )

12

7. Weight (provide a range if necessary )

40

lbs

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

• Gastrointestinal System
  • Symptom - Loss of appetite

• Nervous and Muscular Systems
  • Symptom - Depression

• General
  • Symptom - Pain

• Nervous and Muscular Systems
  • Symptom - Difficulty walking
  • Specify - limping
  • Symptom - Recumbent

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

specify the pet owner was not sure if there had been an exposure.

17. Provide any additional details about the incident

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

Caller has the product and is not sure if his dog could have ingested some. She could have gotten into it within the last week. He states if she did get a hold of the product it would not have been that much possibly a lick, but he is not sure. Dog also lost her litter mate 2 months ago. She has been mopey, limping, not wanting to eat a lot and her back end is hard to get up. Caller was going to take dog to the vet for advice.

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To be determined by Registrant

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

Minor

19. Provide supplemental information here

Causal relationship unclear. Product is contained inside a bait station.