Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-4962

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: BRITISH COLUMBIA

6. Date incident was first observed.

25-DEC-14

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. 25423      PMRA Submission No.       EPA Registration No.

Product Name: FINAL ALL-WEATHER BLOX COMMERCIAL

• Active Ingredient(s)
  • BRODIFACOUM

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7. b) Type of formulation.

Bait

Application Information

8. Product was applied?

No

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 following was reported: The supervisor at (company) illegally distributed brodifacoum to the landlord. The landlord said in a hearing with the residential Tenancy branch that the supervisor gave him several bags... I met (name) once in the hallway with the manager who asked me in front of him if I would allow poison bait in my suite. I did say "No." I was already sick from the poison in ER at the hospital. There was never any attempt to do an 'assessment' of my apartment as it says (company) does on their website. There was a 1 foot by 2 foot hole in my kitchen wall from the landlords plumbers who did not reconstruct the wall when they were done where mice inevitably had access into my suite. I asked them to repair the hole and no one did. The landlord gave poison to a tenant who put 15 blocks in a pile under my floor near a hot pipe! He and the (company) supervisor sealed the poison into the tenants ceiling, that was my floor, and the mice could only get out into my apartment. There were dead and dying mice everywhere!

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

• Eye
  • Symptom - Burning eye
  • Symptom - Watery eye

• Gastrointestinal System
  • Symptom - Stomachache
  • Specify - severe stomachaches

• Respiratory System
  • Symptom - Choking

• Nervous and Muscular Systems
  • Symptom - Headache
  • Specify - severe headaches

• Blood
  • Symptom - Abnormal coagulation
  • Specify - kept bleeding

• General
  • Symptom - Other
  • Specify - cuts and scratches would not heal

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?

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

Respiratory

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: Upon entering the washroom, fumes from the poison and the dead poisoned mouse were making my eyes burn, tear up and it made me choke. Supposedly, the severe stomach and head aches that I had were symptoms of the anticoagulant that was making my capillaries bleed through the veins and it is also why cuts and scratches would not heal and kept bleeding.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Cat / Chat

3. Breed

unknown

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• General
  • Symptom - Death

• Nervous and Muscular Systems
  • Symptom - Seizure

• Gastrointestinal System
  • Symptom - Other
  • Specify - blood in mouth

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

Died

16. How was the animal exposed?

Accidental ingestion/Ingestion accident.

specify ate a mouse

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

The following was reported: My cat was having seizures and he had a pool of his own blood in his mouth and then died after he ate a mouse

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Not Applicable

19. Provide supplemental information here