Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2117

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: ONTARIO

6. Date incident was first observed.

03-APR-15

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. 30075      PMRA Submission No.       EPA Registration No.

Product Name: BEDLAM® INSECTICIDE

• Active Ingredient(s)
  • D-PHENOTHRIN
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE

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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: 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).

The complainant said that (company name) performed an extermination of April 3 2015 in his apartment at location (address). He said the treatment was for bed bugs and two products were used, one of which was Bedlam Insecticide.

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.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Burning eye

• Nervous and Muscular Systems
  • Symptom - Headache

• Respiratory System
  • Symptom - Asthma
  • Specify - asthna like symptoms

4. How long did the symptoms last?

>1 mo and <= 2mos / >1 mois et < = 2mois

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

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Unknown

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

Contact with treated area

Amount of time between application and contact 1.5

Month(s)/ Mois

What was the activity? re-entry to home

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

Unknown

10. Route(s) of exposure.

Unknown

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.)

Since the application (April 3, 2015), he has not been able to live int he apartment. He went in yesterday (May 21, 2015) and began to experience symptoms after being in the apartment for about 20 minutes. He said he was reading the MSDS sheets for the products and was experiencing the symptoms listed on the MSDS including burning eyes, headaches and asthma like symptoms. He spoke with Public Health who referred him to MOE.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.