Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-1482

2. Registrant Information.

Registrant Reference Number: Ont

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: ONTARIO

6. Date incident was first observed.

23-JAN-15

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. 24175      PMRA Submission No.       EPA Registration No.

Product Name: DRAGNET FT EMULSIFIABLE CONCENTRATE INSECTICIDE

• Active Ingredient(s)
  • PERMETHRIN

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PMRA Registration No. 15255      PMRA Submission No.       EPA Registration No.

Product Name: DRIONE INSECTICIDE DUST

• Active Ingredient(s)
  • PIPERONYL BUTOXIDE
  • PYRETHRINS
  • SILICA AEROGEL

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

1

Units: %

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).

The pest control company reports using Dragnet FT (PCPA 24175) as a 1% emulsion to treat the underside of the couch and its frame. Dragnet FT was used to perform a crack and crevice baseboard treatment to the perimether of the affected rooms. In addition, Drione Insecticide Dust was applied through the wall outlets. Steam was also used to treat the bed, mattress, etc..The product was applied by a provincially licensed Pest Control Operator at double the application rate for the control of bedbugs (although the application rate used is allowed on the label for control of other pests indoors).

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: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Other
  • Specify - throat inflammation

• Respiratory System
  • Symptom - Other
  • Specify - chest inflammation

• Gastrointestinal System
  • Symptom - Mouth Irritation
  • Specify - mouth inflammation

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?

No

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 5

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.

Unknown

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.)

The Ministry of the Environment and Climate Change (MOECC) has received a complaint from a tenant at an (city) apartment building. The complainant reports that his unit was treated for bedbugs on Jan 23rd. He returned to his unit 5 hours following the treatment and reports that shortly thereafter, he started 'experiencing mouth, throat and chest inflammation'. He then left the apartment building and spent the night elsewhere. The complainant attended the hospital on January 24 and was informed by the doctor that he had a reaction to a pesticide application.The complainant has not returned to his apartment.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.