Health Canada
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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-3678

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. 24723      PMRA Submission No.       EPA Registration No.


  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


Units: g

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

Site: Personal use / Usage personnel

Préciser le type: arm

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

Aerosol can, used this product for years and always just sprayed it on. Bought two cans as last year there was none available come holiday season. First can used half and left it in my outher tractor, broke this one out as it was in a dry dark storage room and wanted it in my outher baler tractor. Started to spray my arm down as I walked towards my tractor maybe 5 grams out totally, but can weigh the can as I'm not using it and any one is welcome to come take a small sample or be a guinea pig and I sprayed it on there arm. ps. we need to know what to hell is in here, maybe seconds as it spit out in small spats and I thought okay, I put some on my outher arm then wipe it, I had just got the first little bit on my outher arm and I could see holes going into my flesh fast on my left arm I ran to the house as directions said if any allergy or problems just wash immediately with soap and water, which I did three or four times it was clear to me by night time my holes were getting bigger in my flesh so I was worried about infection so sprayed some stuff on it, by morning it hurt like hell, still washing with soap, I could not get it to stop eating my flesh,

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: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • Skin
    • Symptom - Burns (2nd or 3rd degree)

4. How long did the symptoms last?

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

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?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

(continued) You have to understand I am out on a ranch and I have been sent to the hospital with bones sticking out of my arm and sent back home, that's how bad our doctor situation is and I learrned a lot in the last 50 years. I know I have to do some thing immediately to stop this, and resulted in putting baking soda on it as I know baking soda neutralises any forms of acid and that appeared to me exactly what it was doing, that did finally stop it after two applications, but now have deep holes eating into my arm, then put a dry application of silver on as I know from being in the burn centre they still use that as that is what they sent me home with a salve, and still had some, it wasn't until I went to my brother in laws place for a wedding shower. He said get on the phone and tell these people and if it still doesn't heal get into a medical doctor, he took pictures and that was like three weeks later, I immediately called the number on the can when I got home it was the 18, they then transfered me to there toxicologist and she ? Let me finish, she said keep it open and see medical doctor that's easier said that done out here, anyway I took pictures myself that day only one or two open left, rest are healing. I wish I had taken pictures the first 30 minutes as it was actively eating holes in my arm but who thinks of that, my brother in law concerns was younger people of age 10 or over getting this and maybe even getting some on in even more dangerous places of the body, there is either acid in this one can or a misplaced bug killer chemical or some thing very serious and wrong with what went into that can, as any fool knows it was not an allergy or just a reaction or rash. Haven't heard back from them, I also just a few days ago complained on their web site, if they want to be the leading brand of bug repellant they better dam well get on this or it's going on the internet everywhere. I also phoned Walmart where I bought it and talked to the manager. He said go straight to Johnson as they are only a retailer, fine I did that. I work from 5am till 10pm at night seven days a week as I run my ranch myself and I have had a lot to do with chemicals, I have never seen anything like this period. (name) still have scars and one small open and I have both cans, just wasn't getting caught like last year and could get none this years. (number), July 18 3:24pm Reference number#, my cans batch numbers are one that did the damage is J0 83 72944 1336 74, and only a few grams used like 5 as it immediately started eating my flesh in seconds. Outher can is same batch number and used approximately 1/2 of it with no problems can. I have no problems sending my pics but they are on 16 and just yesterday, and I have no problems with someone coming and taking a sample out of that.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.