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: 2009-1368

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.


4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA


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. 24945      PMRA Submission No.       EPA Registration No.


  • Active Ingredient(s)

7. b) Type of formulation.

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).

Applied to approximately 10,000 elm trees in (location) for killing the elm bark beetle. It's sprayed on the bottom of the tree but it goes into the whole tree as I was pulling up to the driveway when they were spraying. They were outfitted in respirators & yellow rainsuits head to foot. I had called the pesticide advisory line (number) & asked that they not spray the tree out front. The woman that answered told me the spray was not poisonous and I believed her. Unfortunetely for me it has turned my life upside down. There is a claim against the city of (name), by myself & (Insurance Company) The city of (name) and said there was a machine on the advisory line.

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: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.


  • Gastrointestinal System
    • Symptom - Salivating excessively
  • Skin
    • Symptom - Tingling skin
    • Specify - fingers and toes tingling
  • Nervous and Muscular Systems
    • Symptom - Disorientation
  • Eye
    • Symptom - Pupil dilation
  • Liver
    • Symptom - Pain
  • Renal System
    • Symptom - Kidney pain
  • Cardiovascular System
    • Symptom - Palpitations
  • General
    • Symptom - Sleepiness

4. How long did the symptoms last?

Unknown / Inconnu

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)


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?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>1 wk <=1 mo / > 1 sem < = 1 mois

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.)

I have extended exposure - severe reaction and still getting ill from the vapors from my belonging here in (city). I am talking Benadryl regularly. Spent $1000 trying to clean the vent system in my 2007 Ford Fusion because I couldn't drive it without a respirator. I had to give it back & pay $200 deductible & $350 for a rented car. I still start salivating, my kidneys hurt, my heart pounds, sometimes my fingers & toes tingle. The worst exposure was Oct.6 -20/08 but this is now in the runoff & through all the vents of cars in (City). This Dursban gets worse when it rains. Its (msds) mixed with petroleum distillate, toluene & xylene is almost the sames as nerve gas. I was never properly treated because the only doctor in (City) who tests for cholinisteraese of city employees wouldn't call back. Sprayed elm tree 20 ' from house and basement suite window was 30 ' from tree on Oct 06/08... very ill by oct.20/08. Disoriented, salivating, kidney hurt, heart pounding, liver heart, tingling in fingers & toes, pupils dilating, sleepy managed to drive to (city) beach where 2 friends came and got me. They could smell the pesticide when they opened the car door. Dow Chemical didn't call back on 24hr emergency line. Not one doctor or the emergency room had any idea how to treat an organophosphate poisoning including the (City) General Hospital so I was not treated with atropine or the Poison Control Centre. The msds doesn't help if no one knows what to do with the poisoining I was referred to an allergist who told me I needed a toxicologist but no one could find one in (city) or (city). The federal person who was investigating whether they used the pesticide properly, doesn't work there as of last week & the man who took his place can't access his files. The msds for this product clearly states not to spray near homes or in schoolyards - that it is toxic to wildlife, aquatic life, birds & bees. One of the provincial men who signs the water permit for the city every year refused to sign this - he said that these permits hadn't even been used for years. Under under organo - phosphate poisonings which includes nerve gas they give the US military 3 vials (2mg each) of atropine to carry with them. The msds for Dursban that says phone any doctor or poison control centre was not poisoned in (city) - not one person had any idea what to do.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.