Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-5570
2. Registrant Information.
Registrant Reference Number: 4798464
Registrant Name (Full Legal Name no abbreviations): Agrium Advanced Technologies RP Inc.
Address: 10 Craig St.
City: Brantford
Prov / State: ON
Country: Canada
Postal Code: N3T 5L4
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
04-JAN-12
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
Unknown
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)
PMRA Registration No. 24175
PMRA Submission No.
EPA Registration No.
Product Name: Dragnet
PMRA Registration No. 19480
PMRA Submission No.
EPA Registration No.
Product Name: Boradust
- Active Ingredient(s)
- BORACIC ACID (BORIC ACID)
PMRA Registration No. 13074
PMRA Submission No.
EPA Registration No.
Product Name: Pyrodust
- Active Ingredient(s)
- PIPERONYL BUTOXIDE
- PYRETHRINS
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).
Product applied by Pest Control company to apartment for roach control
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: Female
Age: >64 yrs / > 64 ans
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Edema
- Symptom - Rash
- Symptom - Red skin
4. How long did the symptoms last?
>1 mo and <= 2mos / >1 mois et < = 2mois
5. Was medical treatment provided? Provide details in question 13.
Yes
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)
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
11. What was the length of exposure?
>1 wk <=1 mo / > 1 sem < = 1 mois
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.)
Apartment sprayed fro roaches by Magical Pest Control with Dragnet, Boradust, and Pyrodust. Has swelling in face and redness and edema rash. Doctor recommended seeing an allergist. Allergist said she had reactions to chemicals. Home was cleaned to remove Dragnet.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.