Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2018-4131
2. Registrant Information.
Registrant Reference Number: 5969257
Registrant Name (Full Legal Name no abbreviations): Sure-Gro IP Inc.
Address: 1900 Minnesota Crt
City: Mississauga
Prov / State: Ontario
Country: Canada
Postal Code: L5N 3C9
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
10-SEP-18
5. Location of incident.
Country: CANADA
Prov / State: NOVA SCOTIA
6. Date incident was first observed.
09-AUG-18
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. 26201
PMRA Submission No.
EPA Registration No.
Product Name: One Shot Wilson Wasp & Hornet Jet Foam
- Active Ingredient(s)
- D-TRANS ALLETHRIN
- N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
- TETRAMETHRIN
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: Unknown / Inconnu
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
unknown
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: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Burns (2nd or 3rd degree)
- Symptom - Erythema
4. How long did the symptoms last?
>3 days <=1 wk / >3 jours <=1 sem
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)
Application
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
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
>3 days <=1 wk / >3 jours <=1 sem
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.)
Caller states that he sprayed some One Shot Wilson Wasp Hornet Jet Foam on Saturday and he must have gotten the product on his hands. So on Monday he noticed some redness and by today he has four small blister and two large ones on his both of his hands. Caller states that he has been treating the areas with Hyderm Cream but it does not seem to be working and the blisters are getting worse; Outcome: Burns (2-3 degree) A. Acute adult dermal - SX Exposure: R.Due to symptoms PC recommends that caller be evaluated by a physician. Case number provided if caller has any other questions or concerns or if he would like the MSDS/SDS sent to the physicians office. Caller will call back to PC if needed Therapies: No therapies recommended
To be determined by Registrant
14. Severity classification.
Moderate
15. Provide supplemental information here.
The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified.