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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-3697

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

Prov / State: ONTARIO

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. 30211      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).

A third party set the Off! Clip-On Mosquito Repellent in the centre of the table we were sitting around, and my spouse was curious how the product worked and began to inspect it. He inhaled the product through his nose to identify if it had a 'citronella' scent to it or not.

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.

2. Demographic information of data subject

Sex: Male

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

3. List all symptoms, using the selections below.


  • Nervous and Muscular Systems
    • Symptom - Unconsciousness
    • Symptom - Unresponsive
  • Gastrointestinal System
    • Symptom - Vomiting
  • Cardiovascular System
    • Symptom - Abnormally high blood pressure
    • Specify - Blood pressure going up and down

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.

<=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.)

Within 30 minutes of this 'inspection' he was unconscious at the table. Completely unresponsive. I could not tell if he was breathing or not, and then he vomited. After the first time he vomited he still was not responsive. A nurse who was sitting at a nearby table came to assist. She attempted the Heimlich manoeuvre on him in case he was choking , and then he vomited again. This is when he regained consciousness and became responsive. The paramedics arrived and tested his blood sugar, blood pressure, and connected turn to the EKG machine. His blood pressure was going up and down but his other tests were normal. In the emergency room his heart rate was normal, his CT scan came back normal, his chest x-ray was normal. A few days later we met with a cardiac specialist and those tests all came back normal. When researching the active ingredient , Metofluthrin , I found that a lot of the symptoms described in lab animals exposed to the product were very similar to the symptoms I witnessed in my spouse the evening he inhaled the product. The product itself is a grey plastic fan like device with a disc that goes inside with the repellent inside it. The packaging for it is clear, with white and orange print. Warnings says not to inhale, and to perform artificial respiration if unable to breathe. Advises to call 911. There are no warnings on the product itself.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.