Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-3262

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.

07-SEP-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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No.

Product Name: unknown

• Active Ingredient(s)
  • ARSENIC PENTOXIDE
  • CHROMIC ACID
  • COPPER (PRESENT AS CUPRIC OXIDE)

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7. b) Type of formulation.

Other (specify)

treated wood

Application Information

8. Product was applied?

Unknown

9. Application Rate.

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

Site: Res. - Out Home / Rés - à l'ext.maison

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

The following was reported: It looks like CCA, it is a balcony floor replacement with white cedar wood that has a strong smell and a light green coloration. I am not sure about the product used to treat the wood, but there is lots of it and it has been recently applied to the wood.

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

• Respiratory System
  • Symptom - Sneezing
  • Symptom - Runny nose

• Eye
  • Symptom - Watery eye
  • Symptom - Itchy eye

• Skin
  • Symptom - Itchy skin

• General
  • Symptom - Malaise

• Nervous and Muscular Systems
  • Symptom - Dizziness

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

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

Contact with treated area

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.

Skin

11. What was the length of exposure?

Unknown / Inconnu

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.)

The following was reported: Whenever I go out to the balcony I get allergy symptoms like skin and eye itching, runny nose and eye, sneezing and a general feeling of uneasy and dizziness.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.