Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-2596

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.

Human

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

14-NOV-12

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. 25673      PMRA Submission No.       EPA Registration No.

Product Name: TEMPO 20 WP INSECTICIDE

• Active Ingredient(s)
  • CYFLUTHRIN

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PMRA Registration No. 26509      PMRA Submission No.       EPA Registration No.

Product Name: PRELUDE 240 SYNTHETIC PYRETHROID INSECTICIDE

• 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).

Les does sont celles mentionnees par l'exterminateur. Le PRELUDE a ete applique le 1er novembre 2012 (30ml/4l d'eau). Le TEMPO a ete applique le 14 novembre 2012 (15ml/4l d'eau). Site de traitment: sous-sol de la residence, le long des plinthes, au contour des fenetres et dans l'espace sous l'escalier. Application par pulverisateur manuel. L'exterminateur n'aurait pas prevenu la plaignante qu'elle devait sortir du logement pendant l'application ni du delai avant de retourner dans le logement. Un echantillonnage a detecte la presence de residus de permethrine (PRELUDE), mais d'aucun autre residu de pesticide.

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.

Other

2. Demographic information of data subject

Sex: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Malaise

• Eye
  • Symptom - Irritated eye
  • Specify - yeux piquent

• General
  • Symptom - Other
  • Specify - odeurs intolerable

• Respiratory System
  • Symptom - Respiratory irritation

• Gastrointestinal System
  • Symptom - Nausea
  • Symptom - Stomach pain
  • Specify - maux d'estomac

• Eye
  • Symptom - Decreased vision
  • Specify - probleme de vision

• General
  • Symptom - Fatigue

4. How long did the symptoms last?

>3 days <=1 wk / >3 jours <=1 sem

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

No

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)

Drift from the application site

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

Eye

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>30 min <=2 hrs / >30 min <=2 h

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.)

La plaignante a ressenti des malaises apres l'application de TEMPO (tout de suite apres l'application) et a du se rendre a l'hopital par ambulance le 3 decembre parce que les symptomes persistaient. Yeux qui piquent, odeurs intolerables, irritations des voies respiratoires, nausees. Elle est retournee chez elle une douzaine d'heures plus tard, apres avoir vu le medecin qui ne semble pas avoir trouve rien d'inquietant. Son mari a ressenti des nausees au cours des premiers jours apres l'application. Ses deux filles de (age) et (age) ont eu les yeux qui piquent et des irrtations legeres au niveau des voies respiratoires pendant quelque jours. Ces trois personnes etaient absentes lors de l'application de TEMPO. Elles sont arrivees sur les lieux quelques heures plus tard. En date du 6 decembre 2012, la plaignante ressent encore dans une moindre mesure des maux d'estomac, nausees, des problemes de vision et de la fatigue. La plaignante etait presentee lors de l'application des produits et n'a pas ete informee qu'elle devait sortir. Elle a observe tout le processus d'application. L'applicateur ne portait d'equipement de protection, ce qui laissait croire a la plaignante que c'etait sans danger.

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.

Other

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Nausea

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?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Contact with treated area

Amount of time between application and contact 3

Hour(s) / Heure(s)

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

Eye

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>24 hrs <=3 days / >24 h <=3 jours

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.)

La plaignante a ressenti des malaises apres l'application de TEMPO (tout de suite apres l'application) et a du se rendre a l'opital par ambulance le 3 decembre parce que les symptomes persistaient. Yeux qui piquent, odeurs intolerables, irritations des voies respiratoires, nausees. Elle est retournee chez elle une douzaine d'heures plus tard, apres avoir vu le medecin qui ne semble pas avoir trouve rien d'inquietant. Son mari a ressenti des nausees au cours des premiers jours apres l'application. Ses deux filles de (age) et (age) ont eu les yeux qui piquent et des irrtations legeres au niveau des voies respiratoires pendant quelque jours. Ces trois personnes etaient absentes lors de l'application de TEMPO. Elles sont arrivees sur les lieux quelques heures plus tard. En date du 6 decembre 2012, la plaignante ressent encore dans une moindre mesure des maux d'estomac, nausees, des problemes de vision et de la fatigue.

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.

Other

2. Demographic information of data subject

Sex: Female

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

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Itchy eye
  • Specify - yeux qui piquent

• Respiratory System
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

>24 hrs <=3 days / >24 h <=3 jours

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

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Contact with treated area

Amount of time between application and contact 3

Hour(s) / Heure(s)

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

Eye

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.)

La plaignante a ressenti des malaises apres l'application de TEMPO (tout de suite apres l'application) et a du se rendre a l'opital par ambulance le 3 decembre parce que les symptomes persistaient. Yeux qui piquent, odeurs intolerables, irritations des voies respiratoires, nausees. Elle est retournee chez elle une douzaine d'heures plus tard, apres avoir vu le medecin qui ne semble pas avoir trouve rien d'inquietant. Son mari a ressenti des nausees au cours des premiers jours apres l'application. Ses deux filles de (age) et (age) ont eu les yeux qui piquent et des irrtations legeres au niveau des voies respiratoires pendant quelque jours. Ces trois personnes etaient absentes lors de l'application de TEMPO. Elles sont arrivees sur les lieux quelques heures plus tard. En date du 6 decembre 2012, la plaignante ressent encore dans une moindre mesure des maux d'estomac, nausees, des problemes de vision et de la fatigue.

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.

Other

2. Demographic information of data subject

Sex: Female

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

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Irritated eye
  • Specify - yeux qui piquent

• Respiratory System
  • Symptom - Respiratory irritation

4. How long did the symptoms last?

>24 hrs <=3 days / >24 h <=3 jours

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

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Contact with treated area

Amount of time between application and contact 3

Hour(s) / Heure(s)

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

10. Route(s) of exposure.

Skin

Eye

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.)

La plaignante a ressenti des malaises apres l'application de TEMPO (tout de suite apres l'application) et a du se rendre a l'opital par ambulance le 3 decembre parce que les symptomes persistaient. Yeux qui piquent, odeurs intolerables, irritations des voies respiratoires, nausees. Elle est retournee chez elle une douzaine d'heures plus tard, apres avoir vu le medecin qui ne semble pas avoir trouve rien d'inquietant. Son mari a ressenti des nausees au cours des premiers jours apres l'application. Ses deux filles de (age) et (age) ont eu les yeux qui piquent et des irrtations legeres au niveau des voies respiratoires pendant quelque jours. Ces trois personnes etaient absentes lors de l'application de TEMPO. Elles sont arrivees sur les lieux quelques heures plus tard. En date du 6 decembre 2012, la plaignante ressent encore dans une moindre mesure des maux d'estomac, nausees, des problemes de vision et de la fatigue.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.