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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-2905
2. Registrant Information.
Registrant Reference Number: AMV
Registrant Name (Full Legal Name no abbreviations): AMVAC Chemical Corporation
Address: 4695 MacArthur Court, Suite 1200
City: Newport Beach
Prov / State: CA
Country: United States
Postal Code: 92660
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
03-AUG-125. Location of incident.
Country: CANADA
Prov / State: QUEBEC
6. Date incident was first observed.
03-JUL-12Product 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. 26509 PMRA Submission No. EPA Registration No.
Product Name: Prelude 240
- Active Ingredient(s)
- PERMETHRIN
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
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).
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: Male
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
- Symptom - Headache
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Unknown
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 house
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
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
Unknown / Inconnu
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.)
Caller states that they sprayed around the apartment 5 days ago and it remained wet for 9 hours after they sprayed. The caller didn't stay in the apartment for the first couple of days but he and his dog have been in there for the past 3 days. Caller states that the dog was licking the floors where there was dry product. Caller has washed the floors, opened his windows and there is still a smell in the apartment. He is wondering if he is being poisoned and how long the smell will persist. Caller does not have asthma and is not a smoker. A: - Inhalation of this product may lead to irritation of the eyes and upper respiratory tract as well as nausea, cough, headache, difficulty breathing, and shortness of breath. - Adverse health effects are typically limited to the upper respiratory tract and resolve without affecting other body functions. - Ventilate the area by opening outside doors and windows. Consider adding portable fans until the odor has dissipated. You may also wash treated surfaces with an appropriate household cleaner. - Patients who smoke or have underlying respiratory conditions may experience more pronounced symptoms that require medical attention.
To be determined by Registrant
14. Severity classification.
Minor
