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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-3416

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: TO BE DETERMINED

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. 26678      PMRA Submission No.       EPA Registration No.

Product Name: C-I-L WASP & HORNET KILLER (1)

  • Active Ingredient(s)
    • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • PERMETHRIN
    • 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: Unknown / Inconnu

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

When she used the pesticide, she basically emptied the container. What she hadn't realized was that, since the nest was located above her head, pesticide residue fell on her and she was not wearing any protective equipment.

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 - Loss of balance
    • Specify - loss of equilibrium
  • Nervous and Muscular Systems
    • Symptom - Difficulty concentrating
    • Specify - difficulty focusing
  • General
    • Symptom - Taste altered
    • Specify - lost her sense of taste
    • Symptom - Other
    • Specify - lost her sense off smell

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)

Application

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.

Unknown

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.)

Last summer, (Mrs. Name) had a problem with hornets so she purchased the pesticide C I L WASP & HORNET KILLER(1) (Reg. No. 26678). She became ill immediately and has had a series of health problems since. She has problems with equilibrium, has difficulty focusing, has lost her sense of taste and smell. She wonders if it may be due to this pesticide whch she misued.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.