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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-4830

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. 27169      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).

Site: Res. - Out Home / Rés - à l'

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

The pesticide was applied by a licensed exterminator to my neighbors home 2 feet from my property by way of power washing their whole home with this spray, not just eaves and windows. The only information the exterminator was able to give me was this label and it appeared as if he himself was unsure of what he was spraying or did not want to tell me. This spray was also applied to 3 other homes the same day and we are less than 40 feet from Lake (name) and they did wear respirators but were not advised of any danger to this pesticide and actually were told it was water soluable and not dangerous what ever that means.

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.

Data Subject

2. Demographic information of data subject

Sex: Male

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

3. List all symptoms, using the selections below.


  • Cardiovascular System
    • Symptom - Abnormally fast heart rate
    • Specify - experienced rapid heart beat
  • Respiratory System
    • Symptom - Difficulty Breathing
  • Cardiovascular System
    • Symptom - Chest pain
  • Gastrointestinal System
    • Symptom - Sore throat
  • Respiratory System
    • Symptom - Coughing
    • Symptom - Other
    • Specify - lung scarring

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)

Drift from the application site

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.

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.)

Even though I was not informed of any danger by the exterminator chose to wear a respirator to protect myself while they were spraying , my wife left for the day as she has chronic bronchitis. After the exterminator left I removed the respirator and continued to work cleaning off my home as the spray coated not only my home, out door furniture, herbs and water system. I myself then experienced rapid heart beat, trouble breathing, and chest pains, sore throat, and cough, in all appearances I thought I was having a heart attack so rushed to the emergency where I was treated and received X-rays and evaluation explaining to the doctor what had happened. I was told I had toxic poisoning and my lungs where now scarred. My wife experienced the same thing even.I am not sure how long this pesticide lingers as I was not informed even what was being sprayed until I begged for this information and they would not supply me with any more, either they did not know or were not being co-operative. We have had more than one incident in this area with exterminators making my dog ill and not advising of their presence. A report of this is at the vets where she also had toxic poisoning symptoms. I feel that this product even if it is a government approved is being mis-used by so-called exterminators, making humans sick, spraying less than 50 feet from the lake and killing honey bees. Baby birds are dropping dead. This spray is being used for cosmetic use only because people do not like spider webs and poop on their siding and making us ill. We are also close to a Provincial Park and if this is a danger to a domestic animal and humans what is it doing to the fish and wild life.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.