Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2016-1714
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
Domestic Animal
4. Date registrant was first informed of the incident.
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
30-SEP-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)
PMRA Registration No. 15330
PMRA Submission No.
EPA Registration No.
Product Name: PRO 110 ULV INSECTICIDE
- Active Ingredient(s)
- PIPERONYL BUTOXIDE
- PYRETHRINS
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
Préciser le type: sprayed house and fogged attic
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Orkin sprayed house and fogged attic for ladybugs. I don't know how much was used but the applicator (name) left fogger in attic to spray, walked away to spray around the house. The fogger was placed incorrectly in the attic, facing the sloping ceiling and fell back on the insulation in one concentrated area, making iti all wetand solvent. This solvent wasn't going away, or evaporating. The time it took to get this fixed only added to the problem thesolvent seeped down into between the walls. It took a 1.5 months from start to finish until we where able to use our bedroom again. Orkin paid forall repairs. They supplied me with MSDS sheet when I requested it.
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: Female
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
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?
Unknown
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Contact with treated area
What was the activity? everyday living
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.
Respiratory
11. What was the length of exposure?
>1 wk <=1 mo / > 1 sem < = 1 mois
12. Time between exposure and onset of symptoms.
Unknown / Inconnu
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.)
30 Sep 2015 (name) fogged attic t 1230, walked away while fogger spraying, came back. Product was spilled in attic. Opened all windows as instructed but smell was overwhelming, had to keep opened for over a week. Tried contacting PCC company but not able to reach someone until Sunday when company (First name Last name) removed solvent impregnated insulation and sprayed enzyme solution then a deodorizer. Saturday night, the smell was too much, we slept in the trailer. Returned on Monday, removed more insulation wet from pesticide, cleaned and left. Pesticide dripped between walls. Company paid for tearing closet/removal insulation, repairs and new insulation. Slept in trailer 2 weeks. Solvent smell gone 19 Oct when restoration company ripped out closet and cleaned up. Headache for over 1 week. Runny nose, headache. Lasted as long as remained in the house. Headache was low grade. No medical treatment received, just went get some fresh air. We have 3 dogs exposed to this. One is now sick with liver and kidney damages but unsure if that is the cause. The other 2 dogs seemed fine.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Renal System
- Symptom - Other
- Specify - kidney damage
- Liver
- Symptom - Other
- Specify - liver damage
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?
Other / Autre
specify f
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
We have 3 dogs exposed to this. One is now sick with liver and kidney damages but unsure if that is the cause. The other 2 dogs seem fine.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Moderate
19. Provide supplemental information here