Health Canada
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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-0551

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. 19919      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. - 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).

Our building superinendent (name) arrived with a grocery cart full of ProRoach Pesticide (500 gram) containers (for several apartments). (name) was only wearing a face mask, gloves. (remember he had on a short sleeved shirt, ie. Bare arms). He applied one container liberally pouring it behind stove, under the kitchen sink cupboards, behind refrigerator and in bathroom, open area next to toilet. Smaller amounts were applied inside the kitchen cupboards (where dishes, cultery and foodstuffs are normally stored. (I cleared cupboards et al in advance of dusting). I asked (name) if it was safe to have this dust next to dishes etc. He said it was safe. When he finished, (name) left a bottle of ProRoach with me (I expect for future applications) which bottle is safely tucked away in the back of lower kitchen sink cupboard.I emailed (name) Corporation, who are the property management company handling: (address) to open a work order to indicate that roaches had returned and request treatment. (Name) opens these emails. In that email Extract: 2) Cochroaches have returned. The dust worked for about a month, now roaches are back. Please note that (name) had literally covered my kitchen cupboard (above and below) with MOUNDS of roach dust in early December, during your all apartments dusting. I cannot clean up this old dust. You will have to have your people carefully clean it up before reapplying gel. I found this roach dust can be hazardous for anyone with slight respiratory problems. If the dust is slightly disturbed it rises and can cause immediate throat constriction. Not sure if vacuuming should be done, unless there is a filter attached to the exhaust part of the vacuum; otherwise roach dust will be spewed everywhere. I have made reference to (superintendent, company name) applying the dust in early December 2013. For some reason, I thought it was moved up 2 weeks to December 2013. This may be wrong, it should read November 2013 per the actual (company name) Notice dated November 13,2013 for treatment on November 15,2013. Note No other treatments have been performed since that time. Postcript 1) Perhaps related symptoms: Not sure, but I may as well mention that I have been experiencing lip numbness many times over the last few weeks which appears to only happens when I am in the apartment all day. It is relieved when I leave the apartment. My boyfriend and 2 grandchildren (who stay with me on weekends) have not reported anything peculiar to me, possibly a headache here which I have been attributing to a cold or flu. Postcript2): the building is very old and porous. Because of this, we are exposed to harsh fumes similar to those of weed and cigarette smokers of those who also reside in the same building. Fumes enter via the kitchen and bathroom via vents, plumbing, open windows and any other gaps in structure. Now concerned, if any apartments are sprayed.does the spray travel throughout the apartments.

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: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • Respiratory System
    • Symptom - Difficulty Breathing
    • Symptom - Other
    • Specify - throat constriction

4. How long did the symptoms last?

<=30 min / <=30 min

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)


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?

>1 mo <= 6 mos / > 1 mois < = 6 mois

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.)

On or around January 16, I spilled some food between kitchen counter and refrigerator. Noting there was some roach dust there, I proceeded to sweep it up gently, kneeling down with the dustpan in hand. I was immediately hit with throat constriction, loss of breathe. I pulled away immediately; it took me about 30 seconds to 1 minute to recover. I asked boyfriend to take care of it......he vacuumed it up and did not appear to suffer any ill effect. I definitely attribute this immediate and unexpected reaction to my proximity and exposure to the dust; but since I recovered rapidly, I did not seek medical attention nor thought to report it. While I did make a mental note to report it to (company), I was not aware that I should be reporting this to either the manufacturer, the Ministry of the Environment or Health Canada.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.