Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2020-4862

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: x

City: x

Prov / State: x

Country: x

Postal Code: X

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

Environment

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: PRINCE EDWARD ISLAND

6. Date incident was first observed.

04-OCT-20

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.       PMRA Submission No.       EPA Registration No.

Product Name:

• Active Ingredient(s)
  • 4-AMINOPYRIDINE

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

Product Name:

• Active Ingredient(s)

---

7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

9. Application Rate.

Unknown

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

Site: Unknown / Inconnu

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

Additional information unknown.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

Subform IV: Environment (includes plants insects and wildlife)

1. Type of organism affected

Bird - Flocking/Oiseau-Vivant en colonie

2. Common name(s)

Rock Pigeon

3. Scientific name(s)

Columba livia

4. Number of organisms affected

1

5. Description of site where incident was observed

Fresh water

Terrestrial

Residential

Salt Water

6. Check all symptoms that apply

Death

7. Describe symptoms and outcome (died, recovered, etc.).

A Rock pigeon was presented to the clinic. It was seizuring/trembling, head rolling, foaming from the beak. The pigeon received two doses of diazepam injections in the pectoral muscle to stop seizures. It's feet were placed in a cool bath to stop overheating due to seizures. It died 20 minutes after intake. The bird was submitted to the Canadian Wildlife Health Cooperative (CWHC) at the Department of pathology. Necropsy findings suggested Avitrol poisoning and samples were collected for confirmation.

8. a) Was the incident a result of (select all that apply)

Unknown

8. b) i) How many times has the product been applied this year?

Unknown

8. b) ii) What was the date of the last application?

Unknown

9. Did it rain

9. a) During application?

Unknown

9. b) Up to 3 days after application?

Unknown

10. a) Was there a buffer zone?

Unknown

10. b) What type?

10. c) What was the size of the buffer zone?

11. a) Were environmental samples collected and analysed?

Unknown

To be determined by Registrant

12. Severity classification (if there is more than one possible classification, select the most severe)

Minor

13. Please provide supplemental information here