Health Canada
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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2018-2126
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.
05-JUN-18Product 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. PMRA Submission No. EPA Registration No.
Product Name: Avitrol
- Active Ingredient(s)
- 4-AMINOPYRIDINE
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).
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 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
Other
Salt Water
6. Check all symptoms that apply
Abnormal behavioural effects
Death
7. Describe symptoms and outcome (died, recovered, etc.).
The following was reported: A suspect Avitrol poison Rock Pigeon was found in x, at the x parking lot on June 5, 2018. It appeared to be rocking, trying to fly, but was unable to use its legs. It was brought to the Atlantic Veterinary College Wildlife Service, where it was found dead on arrival on June 5, 2018. It was submitted to the Canadian Wildlife Health Cooperative at the Pathology Department at the AVC on June 6, 2018. Results of the necropsy are pending.
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?
Aquatic
10. c) What was the size of the buffer zone?
11. a) Were environmental samples collected and analysed?
Unknown
