Health Canada
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Consumer Product Safety
Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2020-1104
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: BRITISH COLUMBIA
6. Date incident was first observed.
01-MAY-20Product 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: Unknown
- Active Ingredient(s)
- BRODIFACOUM
- BROMADIOLONE
7. b) Type of formulation.
Bait
Application Information
8. Product was applied?
Unknown
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Pub. Area - Outdoor/Zone publique - ext
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
The following was reported: I am very concerned about the condition of the bait traps at the x. I have already reported to the IPM Officer this incident but the label has not been changed yet. I called the company on the label and was told that they have been purchased by xx 3 months ago. The bait boxes do not have the current company label on them. They look like they have been unattended for some time. One label did no have any compound ticked off. One bait box was covered with overgrown vegetation.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 - Predatory / Oiseau - De proie
2. Common name(s)
Great Horned Owl
3. Scientific name(s)
Bubo virginianus
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
Death
7. Describe symptoms and outcome (died, recovered, etc.).
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?
Terrestrial
10. c) What was the size of the buffer zone?
11. a) Were environmental samples collected and analysed?
Yes
