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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-1346
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
Domestic Animal
4. Date registrant was first informed of the incident.
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
21-NOV-06Product 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)PMRA Registration No. PMRA Submission No. EPA Registration No.
Product Name:
- Active Ingredient(s)
- ABAMECTIN
- DICOFOL
- FENBUTATIN OXIDE
- PYRIDABEN
7. b) Type of formulation.
Application Information
8. Product was applied?
Unknown
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Res. - In Home / Rés. - à l'int. maison
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Unknown, although from photos obtained of grow operation unit discovered next door, spray equipment was used indoor and photo also show bottles and contains of pesticides, miticides, feralizers used. Discovery: July 3, 2008To 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: Unknown
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Respiratory System
- Symptom - Nasal congestion
- Symptom - Other
- Specify - post nasal drip
- Symptom - Coughing
- Nervous and Muscular Systems
- Symptom - Ataxia
- Specify - 'dysptonia'
- Symptom - Headache
- Symptom - Dizziness
- Symptom - Depression
- Specify - depressed mood anxiety
- Symptom - Anxiety
- Skin
- Symptom - Lesion
- Specify - skin outbreak
- Symptom - Other
- Specify - lichen simplex chroniticus
- Symptom - Other
- Specify - prurigo popularis
4. How long did the symptoms last?
>6 mos / > 6 mois
5. Was medical treatment provided? Provide details in question 13.
Yes
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
Unknown
11. What was the length of exposure?
>1 yr / > 1 an
12. Time between exposure and onset of symptoms.
>6 mos / > 6 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.)
Since Janauary 29, 2008, right knee pain & neuropraxia right tibital nerve after compresion from sleeping (? sedation from toxiticity) on sofa. [word unclear] right calf and foot. Over last period since January 2008, nasal congestion, post nasal drip, cough, dysptonia. Patient also had headaches, dizziness, depressed mood & anxiety. She also developed skin outbreaks during the exposure period; lichen simplex chronicus? and prurigo papularis.Neighboring unit in apartment building was found to be a grow operation for marijuana plants. Exposure during unknown. Black mould was also found in her kitchen cabinets & walls. Her dog & cat died following /during these exposures as well. Due to her illness since January 2008, pt has seen multiple specialists (respirologist, psychiatry, neurologist, toxicologist, ENT) and rehabilitation therapists for treatment.
To be determined by Registrant
14. Severity classification.
15. Provide supplemental information here.
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
Domestic Shorthair tricolour
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Respiratory
Unknown
9. What was the length of exposure?
>1 yr / > 1 an
10. Time between exposure and onset of symptoms
>2 mos <=6 mos / > 2 mois < = 6 mois
11. List all symptoms
System
- General
- Symptom - Death
- Gastrointestinal System
- Symptom - Loss of appetite
- General
- Symptom - Lethargy
- Nervous and Muscular Systems
- Symptom - Loss of coordination
- Specify - loss of balance
- Symptom - Lameness
- Specify - dragging back right leg
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
16. How was the animal exposed?
Other / Autre
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Dog acted out of character but cat taken to emergency veterinarian. treated. Approximately 4 weeks later cat became lethargic, lost balance (fell from window sill). loss of appetitie. Veterinarian notified [words unclear] of incident. Cat began to drag his back R leg. Please see attached sheets, timelines and autopsy reports and diagnostics. Neighboring unit in apartment building was found to be in large grow operation for marijuana plants. Exposure duration unknown although police estimate access to apt was from approximately 07/06 - 07/08. Black mould was also found in kitchen cabinets & walls - see attached reports. Cat was an 'indoor cat'. Dog also died on 10/07. Owner was affected as well with headaches, dizziness, blackouts, skin outbreaks, mood swings, nasal congestion, post nasal drip, cough, [word unclear], damage to nerve system. Loss of feeling, on parts of body. High levels of black mould. Some of the containers in photos were not identified.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Not Applicable
19. Provide supplemental information here
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Lab
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Respiratory
Unknown
9. What was the length of exposure?
>1 yr / > 1 an
10. Time between exposure and onset of symptoms
>6 mos / > 6 mois
11. List all symptoms
System
- General
- Symptom - Death
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
16. How was the animal exposed?
Other / Autre
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Dog acted out of character. Neighboring unit in apartment building was to be in large grow operation for marijuana plants. Exposure duration unknown although police estimate access to apt was from approximately 07/06 - 07/08. Black mould was also found in kitchen cabinets & walls. Cat was an 'indoor cat'. Dog also died on 10/07. Owner was affected as well with headaches, dizziness, blackouts, skin outbreaks, mood swings, nasal congestion, post nasal drips, cough, dyspnea, damage to nerve system. Loss of feeling, on parts of body.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Not Applicable
