Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-7046

2. Registrant Information.

Registrant Reference Number: 6105057

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.

21-AUG-19

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

21-AUG-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. 15975      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Tomato Fruit Set Spray

• Active Ingredient(s)
  • 4-CPA

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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

unknown

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

25

lbs

8. Route(s) of exposure

Oral

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 - Diarrhea

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

Caller stated they found a bottle of the product chewed up. Said it's possible her dog was exposed to product. Does not know when it happened but said bottle was pretty full and now it is empty. Caller said their dog had an x-ray that morning and had been sedated for that so she was still lethargic from that. Said that dog had diarrhea. Recommendation provided was to wash muzzle/paws, and to give access to clean water. Advised to consult vet if symptoms persisted or worsened and to call back if there were any questions.

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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

Not clear if there was any observation of product around chewed bottle; unclear whether the dog chewed a full bottle or an empty bottle after contents had spilled.