Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-6383

2. Registrant Information.

Registrant Reference Number: 2019-42

Registrant Name (Full Legal Name no abbreviations): BASF Canada Inc.

Address: 100 Milverton Drive, 5th Floor

City: Mississauga

Prov / State: Ontario

Country: Canada

Postal Code: L5R 4H1

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

14-NOV-19

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

14-NOV-19

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. 28403      PMRA Submission No.       EPA Registration No.

Product Name: Prescription Treatment Brand AVERT Dry Flowable Cockroach Bait Formula

• Active Ingredient(s)
  • ABAMECTIN

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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).

A company came to the workplace and spread this product through the work facility. They covered most of the floor and shelving with plastic before applying product.

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 - Conjunctivitis
  • Symptom - Discharge eye

• Skin
  • Symptom - Edema

• Respiratory System
  • Symptom - Coughing
  • Symptom - Respiratory irritation
  • Symptom - Burning throat
  • Symptom - Other
  • Specify - Pneumonitis

• Eye
  • Symptom - Irritated eye

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Unknown

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

Contact with treated area

Amount of time between application and contact 12

Hour(s) / Heure(s)

What was the activity? Cleaning up and folding of plastic that was used to cover the workplace while pesticide was used.

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Goggles

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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 company covered most of the floor and shelving with plastic before applying the product. The affected individual used gloves, glasses and an apron while folding the plastic carefully and discarding it in a trash can, to clean up the office after the product was applied. They were seen by a doctor and was put on an anti-inflammatory drug. She was diagnosed with pneumonitis and eye irritation. Most recent communication updated that there was slight improvement in symptoms.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.