Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2024-1715

2. Registrant Information.

Registrant Reference Number: 6769079

Registrant Name (Full Legal Name no abbreviations): Premier Tech Ltd.

Address: 1 avenue Premier

City: Riviere-du-Loup

Prov / State: Quebec

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.

08-FEB-24

5. Location of incident.

Country: CANADA

Prov / State: NEWFOUNDLAND

6. Date incident was first observed.

08-FEB-24

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. 29427      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Mouse Out Rat and Mouse Killer Pellets

• Active Ingredient(s)
  • CELLULOSE (FROM POWDERED CORN COBS)

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Other / Autre

Préciser le type: Inside Barn

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

Caller did not provide additional information on the use/application of the product.

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

Yorkshire Terrier

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

0

7. Weight (provide a range if necessary )

3.2

kg

8. Route(s) of exposure

Oral

9. What was the length of exposure?

>2 hrs <=8 hrs / >2 h <=8 h

10. Time between exposure and onset of symptoms

>2 hrs <=8 hrs / > 2 h < = 8 h

11. List all symptoms

System

• Nervous and Muscular Systems
  • Symptom - Agitation

• Gastrointestinal System
  • Symptom - Vomiting

• Nervous and Muscular Systems
  • Symptom - Depression
  • Symptom - Shaking

• General
  • Symptom - Lethargy

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?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

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

Wilson Mouse Out Mouse & Rat Killer Pellets was applied in a barn and dog may have ingested the product. When animal owner called, dog had vomited 30 minutes ago and became shaky and lethargic. Dow owner was advised to monitor symptoms and get veterinarian attention if symptoms persist or are worrisome (watch for excessive or intermittent vomiting).

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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

The information contained in this report is based on self-reported statements provided to the registrant during telephone interview. These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for as determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interview.