Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2020-1975

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.

03-JUN-20

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. 24175      PMRA Submission No.       EPA Registration No.

Product Name: Dragnet

• Active Ingredient(s)
  • PERMETHRIN

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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: 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: My neighbour hired the company (name) to spray their property for mosquitoes with Dragnet. They have come on two occasions and are not supposed to spray near the patio area, but they have both times. The intake vent to my house is near the property line, and somehow the Dragnet has entered my home on both occasions that they came to spray. I was not sure the first time as I hadn't felt the sensations before and thought that it might have been something else. Once I experienced the same symptoms the second time I knew it must be the Dragnet. Once I started to feel the same issues again, my husband happened to enter our furnace room (that has no windows for ventilation, only the fresh air intake vent) and noticed a strong chemical smell shortly after they were here spraying. I contacted my neighbour right away and the company to inform them and ask what they were spraying and for the MSDS sheet.

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 - Tingling skin
  • Specify - lips, face and nose
  • Symptom - Burning skin
  • Specify - lips, face and nose

• Gastrointestinal System
  • Symptom - Tingling in mouth

• General
  • Symptom - Swelling
  • Specify - face, mouth, and nostrils

• Eye
  • Symptom - Watery eye

• Nervous and Muscular Systems
  • Symptom - Dizziness

• Respiratory System
  • Symptom - Irritated nose
  • Specify - tingling in nostrils
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

>8 hrs <=24 hrs / > 8 h < = 24 h

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)

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.

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: Burning and tingly sensation on my lips and face, and in my nose. Mouth and nostrils felt swollen and tingly. Eyes were watering and my face felt swollen. A couple of hours after the exposure I felt dizzy and had some breathing discomfort

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.