Incident Report

Subform I: General Information

1. Report Type.

Update the report

Incident Report Number: 2009-5411

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: BRITISH COLUMBIA

6. Date incident was first observed.

07-AUG-09

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 FT EMULSIFIABLE CONCENTRATE INSECTICIDE

• Active Ingredient(s)
  • PERMETHRIN

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PMRA Registration No. 15330      PMRA Submission No.       EPA Registration No.

Product Name: PRO 110 ULV INSECTICIDE

• Active Ingredient(s)
  • PIPERONYL BUTOXIDE
  • PYRETHRINS

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PMRA Registration No. 25673      PMRA Submission No.       EPA Registration No.

Product Name: TEMPO 20 WP INSECTICIDE

• Active Ingredient(s)
  • CYFLUTHRIN

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

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

Site: Res. - In Home / Rés. - à l'int. maison

Préciser le type: Apartment, residence

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

One applied by fogging and one applied around perimeter. I have not been able to get information as to which was used in fogging. (.)Dragnet should not have been used this way) The following is the application rate used last week in another apartment in my building. Dragnet 0.5% Permethrin PC24175-110ULV 1.0%. I do not know if the same application was used in my apartment in August'09.Reported to PMRA Ottawa. Talked to Iulia Popa (Call line), Ilze Rupners (CLSROD B.C.),Also to Dept. of Environment-Pesticide Control in Surrey B.C.

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

• Gastrointestinal System
  • Symptom - Dry mouth

• Skin
  • Symptom - Burning skin
  • Specify - Face burning

• Nervous and Muscular Systems
  • Symptom - Trembling

• Gastrointestinal System
  • Symptom - Nausea

• Skin
  • Symptom - Erythema

• Nervous and Muscular Systems
  • Symptom - Difficulty talking
  • Specify - Impaired speech

• Skin
  • Symptom - Paresthesia
  • Symptom - Rash

• Eye
  • Symptom - Glazed eye

• Skin
  • Symptom - Other
  • Specify - rough
  • Symptom - Peeling skin
  • Specify - scaly skin

• Nervous and Muscular Systems
  • Symptom - Headache
  • Symptom - Memory loss
  • Symptom - Confusion

• General
  • Symptom - Hypothermia

4. How long did the symptoms last?

>2 mos and <=6mos />2 mois et <=6mois

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

Yes

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Contact with treated area

What was the activity? Living in treated area

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

None

10. Route(s) of exposure.

Skin

Eye

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>24 hrs <=3 days / >24 h <=3 jours

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.)

First symptoms occured day after spraying August8'09. Tingling and prickling all over body. Went to walk-in clinic doctor did not know what to recommend other that if it got worse go to the ER. August 10 reaction was much worse. Face burning and red ; eyes glossy; speech impaired. Caller neighbour who took me to ER doctor called Poison Control Center. They said I was having an allergic reaction to the Permethrin. Prescribed Benadryl. August 11 went to see my family doctor who said it was not an allergic reaction but that I had been poisoned by the Permethrin. He advised leaving the apartment for 3-4 week. Before returning to my Apt. I had it washed down. I am continuing to have symptoms. Burning all over body; dry mouth;trembling;nausea;paresthesia. Large rash all over thighs. Patches of rough and scaly skin. Dec07'09. Went to ER was given RX.:Hyderm1% and Apo-hydroxyzin 10mg. Every reaction is worse than last. This is not enough room for me to go into every detail but this has been going on for 4 months. Also get very cold with severe reaction. Headaches. Effects cognitive functiosn, memory, confusion. Apartment was sprayed on August 7'09 for bedbugs. Do not know but see above.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.