Incident Report

Subform I: General Information

1. Report Type.

Update the report

Incident Report Number: 2013-2699

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.

Human

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

16-APR-13

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. 24175      PMRA Submission No.       EPA Registration No.

Product Name: DRAGNET FT EMULSIFIABLE CONCENTRATE INSECTICIDE

• Active Ingredient(s)
  • PERMETHRIN

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

10

Units: L

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

Site: Res. - In Home / Rés. - à l'int. maison

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

Le pesticide a ete applique au sous-sol d;une residence privee, tout le long des bas de murs du perimetre exterieur, de maniere apparement conforme aux instructions de l'etiquette. La dose etait de 10ml de DRAGNET/L d'eau dans un pulverisateur manuel.

To be determined by Registrant

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

Unknown

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Nausea

• Respiratory System
  • Symptom - Respiratory irritation

• Nervous and Muscular Systems
  • Symptom - Headache

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Drift from the application site

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

None

10. Route(s) of exposure.

Skin

Eye

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

Lors du traitement au sous-sol, les occupants etaient au rez-de-chaussee. Il semble que l'echangeur d'air etait en fonction en mode recirculation et que des emanations du pesticides aient ete diffusees dans toute la maison. Pendant le traitement, la personne a senti l'odeur du produit et a ete incommodee fortement. Elle a contacte info-sante qui lui a recommande de sortir immediatement a l'air frais. Selon les renseignements recueillis par l'agente regionale des pesticides, l'exterminateur n'a pas renseigne les occupants sur les mises en garde de l'etiquette avant le traitement, seulement apres avoir constate le malaise de la personne. Le nom du produit ou l'etiquette n'a pas ete fourni aux occupants. La personne incommodee dit toujours souffrir d'irritations aux voies respiratoires, mais n'a pas eu d'avis medical a ce sujet pour verifier le lien avec le pesticide. Irritations des voies respiratoires (symptome qui perdure), nausees, maux de tete

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.