Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2021-2910

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.

16-JUN-21

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: AVITROL (UNSPECIFIED FORMULATION)

• Active Ingredient(s)
  • 4-AMINOPYRIDINE
    • Guarantee/concentration .5 %

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7. b) Type of formulation.

DETERRENT

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).

This rock pigeon (ID#AVC-W-2021-174), was found at Joe Gizz park, between Grafton and Kent St., Charlottetown, PE, on June 17, 2021. The pigeon was sitting, walking, limping in circles.

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)

Pigeon

3. Scientific name(s)

Unknown

4. Number of organisms affected

1

5. Description of site where incident was observed

Fresh water

Terrestrial

Other

Salt Water

6. Check all symptoms that apply

Impairment of health

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

On physical examination this pigeon was a suspect Avitrol poisoning. It had dilated pupils, broken feathers, and scabbed blood along abrasion on right ventral pectoral muscle, empty crop, red feet, hot to touch, red cloaca, two scabs found on both hocks starting to tear away (possible secondary to flailing during seizure). Left body and head tilt. A dose of Diazepam was administered. It took affect and the pigeon calmed down. The bird was cooled down by cooling its feet. It was subdued and wasn't eating for two days and was gavage fed Exact formula. On day 4 if was able to keep its weight up and self feeding.

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)

13. Please provide supplemental information here