Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2019-1700
2. Registrant Information.
Registrant Reference Number: 5991516
Registrant Name (Full Legal Name no abbreviations): Premier Tech Ltd.
Address: 1 avenue Premier,
City: Riviere-du-Loup,
Prov / State: Quebec
Country: Canada
Postal Code: G5R 6C1
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
12-NOV-18
5. Location of incident.
Country: CANADA
Prov / State: UNKNOWN
6. Date incident was first observed.
09-OCT-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. 28788
PMRA Submission No.
EPA Registration No.
Product Name: Wilson One Shot House & Garden Insect Killer
- Active Ingredient(s)
- D-PHENOTHRIN
- 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: 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).
applied product in some drawers
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
No
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: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
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)
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.
Respiratory
11. What was the length of exposure?
>1 wk <=1 mo / > 1 sem < = 1 mois
12. Time between exposure and onset of symptoms.
>1 wk <=1 mo / > 1 sem < = 1 mois
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 she sprayed some drawers in her home with Wilson One Shot House Garden Insect Killer and the smell is very strong O: A: R: Tried to explain to caller about Pyrethroids and she just disagrees Product is water soluble Wash all hard surfaces with warm soapy water and was all beddings Transferred to SPI
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
product was not use per the directions outlined on the label. Product is not approved for application in drawers. 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.