Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2019-7047
2. Registrant Information.
Registrant Reference Number: 6106217
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.
24-AUG-19
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
17-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)
PMRA Registration No. 30836
PMRA Submission No.
EPA Registration No.
Product Name: Wilson Warfarin ReUseable Bait Station
- Active Ingredient(s)
- WARFARIN (PRESENT IN FREE FORM OR AS SODIUM SALT)
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
unknown
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
2
7. Weight (provide a range if necessary )
10
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
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
Fully Recovered / Complètement rétabli
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 her dog may have ingested some bait out of a Wilson Warfarin ReUseable Bait Station Kit possibly last week. Caller stated that the station was empty and the dog vomited once last week; no symptoms ever since.
Recommendation provided was to wash muzzle/paws and provide access to fresh food and water. Watch for any changes in bowel/eating habits. Advised to consult vet if symptoms occur and to call back there were any questions.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here