Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-4531

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: x

City: x

Prov / State: x

Country: 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.

23-MAR-10

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. 25739      PMRA Submission No.       EPA Registration No.

Product Name: VET-KEM SIPHOTROL 1000

• Active Ingredient(s)
  • (S)-METHOPRENE
  • PERMETHRIN

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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).

My friend told me to spray between the mattresses, I took her word because she sprays furniture with it and carpet and has two elderly parents and has had no problem. However they have a central air ventilation system. That night I told dad not to sleep in his room one more night but the untreated living room as he had been due to bites recd in bed for two weeks. I sprayed between the mattresses lightly not on top nor any bedding, the perimeter floor and the window sill crevice where the cat sat a lot. I told him to close the bedroom dorr and leave the window wide open and not sleep in there for the night. However, being elderly and on his own, he did not listen and slept there that night and kept the window closed even though I had left it open. Then you know the rest.

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.

2. Demographic information of data subject

Sex: Male

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Death

• Respiratory System
  • Symptom - Other
  • Specify - lung xray showed massive scarring

• Nervous and Muscular Systems
  • Symptom - Coma

4. How long did the symptoms last?

Persisted until death

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

Yes

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

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

Contact with treated area

What was the activity? re-entry

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

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.)

I am the daughter that reported the incident. The product that was used was the 1000 dose. Purchased under dad's name (first name last name), February 27 2010 from (name) Animal clinic in (city)(phone number) can confirm with (name) the receptionist. I asked the hospital to check for the pesticide at (name) in (city) BC as Dad died (date). An autopsy was performed, as the executor you have my permission to research the results. I asked them to look for the possibility of poisoning by the pesticide.I do not know if they did the appropriate testfor that. He has since been creamated. I do not know if they still have any samples of the lung tissue on file. I know that the lung xray showed massive scarring and he could not breath without the ventilator. I was pressured into removing life support as they felt he would never be able to be off the vent and his quality of life would be minimal if he ever did come out of the coma which they said was very unlikely. It was very traumatic for me holding him while he took his last breaths and his heart stopped. I know it has been over two years since his death. I only saw your report today and realized it was the one I gave to the manufacturer. Had I known this I would have contacted the hospital to give you a lung sample when the autopsy was done. I did give the manufacturer my name and phone number. My phone number is (phone number) (name). During the same month of his death....I developed dystonia which has worsened over time. I know chemical exposure can be one of the causes for that too among other things. I have ongoing orthomandibular cervical dystonia dysphagia, onset at the time of Dad hospitalization and death.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

2. Demographic information of data subject

Sex: Female

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

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Muscle spasm
  • Specify - orthomandibular cervical dystonia

• Gastrointestinal System
  • Symptom - Difficulty swallowing
  • Specify - dysphagia

4. How long did the symptoms last?

>6 mos / > 6 mois

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

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

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

Application

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.

Unknown

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.)

I am the daughter that reported the incident. The product that was used was the 1000 dose. Purchased under dad's name (first name last name), February 27 2010 from (name) Animal clinic in (city) (phone number) can confirm with (name) the receptionist. I asked the hospital to check for the pesticide at (name) in (city) BC as Dad died (date). An autopsy was performed, as the executor you have my permission to research the results. I asked them to look for the possibility of poisoning by the pesticide.I do not know if they did the appropriate testfor that. He has since been creamated. I do not know if they still have any samples of the lung tissue on file. I know that the lung xray showed massive scarring and he could not breath without the ventilator. I was pressured into removing life support as they felt he would never be able to be off the vent and his quality of life would be minimal if he ever did come out of the coma which they said was very unlikely. It was very traumatic for me holding him while he took his last breaths and his heart stopped. I know it has been over two years since his death. I only saw your report today and realized it was the one I gave to the manufacturer. Had I known this I would have contacted the hospital to give you a lung sample when the autopsy was done. I did give the manufacturer my name and phone number. My phone number is (phone number) (name). During the same month of his death....I developed dystonia which has worsened over time. I know chemical exposure can be one of the causes for that too among other things. As per daughter ' I have ongoing orthomandibular cervical dystonia dysphagia, onset at the time of Dad hospitalization and death.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.