Health Canada
Symbol of the Government of Canada
Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-5561

2. Registrant Information.

Registrant Reference Number: 1-15026683

Registrant Name (Full Legal Name no abbreviations): Whitmire Micro-Gen Research Laboratories, INC

Address: 3568 Tree Court Industrial Blvd.

City: St. Louis

Prov / State: MO

Country: USA

Postal Code: 63122

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


4. Date registrant was first informed of the incident.


5. Location of incident.


Prov / State: TEXAS

6. Date incident was first observed.


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.


PMRA Registration No.       PMRA Submission No.       EPA Registration No. 499404

Product Name: Prescription Treatment brand Ultracide Pressurized IGR & Adulticide

  • Active Ingredient(s)
      • Guarantee/concentration .4 %
      • Guarantee/concentration .4 %
      • Guarantee/concentration .05 %
      • Guarantee/concentration .1 %

7. b) Type of formulation.

Other (specify)


Application Information

8. Product was applied?


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?


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.


  • Eye
    • Symptom - Blurred vision
  • Respiratory System
    • Symptom - Shortness of breath
  • General
    • Symptom - Malaise
  • Cardiovascular System
    • Symptom - Chest pain

4. How long did the symptoms last?

>2 hrs <=8 hrs / > 2 h < = 8 h

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


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


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


Contact with treated area

Amount of time between application and contact 1

Hour(s) / Heure(s)

What was the activity? Work application

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


10. Route(s) of exposure.


11. What was the length of exposure?

>15 min <=2 hrs / >15 min <=2 h

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 h

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.)

Adult male with symptoms of chest pain, shortness of breath, lack of energy and inability to focus eyes. He stayed in room for 10-15 min. where product was sprayed. Symptoms developed 90 min. later and persist through evening. Advised that symptoms could be from inhalation but would be resolved with time and fresh air. Advised that after 6 hour medical attention should be sought. On Recall subject still was having symptoms but does not have medical insurance, encouraged him to discuss with supervisors to reevaluate medical attention. Suggested seeking alternate means of obtaining medical assistance.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.