Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-7019

2. Registrant Information.

Registrant Reference Number: 6074297

Registrant Name (Full Legal Name no abbreviations): PremierTech Ltd.

Address: 1, avenue Premier

City: Riviere-du-Loup

Prov / State: QC

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.

06-JUN-19

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

05-JUN-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. 21850      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Hose Spray Malathion Insecticide-Miticide

• Active Ingredient(s)
  • MALATHION

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7. b) Type of formulation.

Application Information

8. Product was applied?

No

9. Application Rate.

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

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

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

• Skin
  • Symptom - Irritated skin

• Nervous and Muscular Systems
  • Symptom - Headache

• Cardiovascular System
  • Symptom - Abnormally high blood pressure

• Respiratory System
  • Symptom - Irritated nose

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)

Pesticide Spill

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

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

<=15 min / <=15 min

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.)

Caller originally called to inquire about cleaning her car where a spill had occurred. Also asked if she should be concerned since she breathed it in. Exposure was described as brief. Caller rinsed her right nostril thoroughly the day of the exposure to address irritation. On second day she had a headache. Caller was planning to see Health Care Provider if headache persisted.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Caller reported that she takes medication for high blood pressure. Felt like her blood pressure was high when first exposed. High blood pressure potentially unrelated. Caller refused a callback but said she would call if she had any questions. Additional calls were received on June 6 asking for advice on how to clean car.