Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-1591

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: ONTARIO

6. Date incident was first observed.

10-APR-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. 24858      PMRA Submission No.       EPA Registration No.

Product Name: KONK 400 RESIDUAL INSECTICIDE SPRAY WITH BAYGON

• Active Ingredient(s)
  • PIPERONYL BUTOXIDE
  • PROPOXUR

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PMRA Registration No. 24175      PMRA Submission No.       EPA Registration No.

Product Name: DRAGNET FT EMULSIFIABLE CONCENTRATE

• Active Ingredient(s)
  • PERMETHRIN

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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: Pub. Area - Indoor/Zone publique - int

Préciser le type: Prep area of kitchen and the perimeter of the kitchen.

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

At two separate times (Wednesday April 8th, 2015 and Friday April 10, 2015), (Company) visited prep area of the kitchen. Applications were applied after lunch hours, students were vacated. April 8th, a gel was applied at about 2pm to the area contained within the prep table. On April 10, full crack and crevice to all kitchen table and perimeter within the kitchen. 30 gram of Konk 400/0.5% (gel), 1.5L of Dragnet FT Emulsifiable Concentrate, 454ml of Konk 400 with Bagon.

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

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Headache

• General
  • Symptom - Lightheadedness

4. How long did the symptoms last?

>2 hrs <=8 hrs / > 2 h < = 8 h

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

Occupational

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

Contact with treated area

What was the activity? Supervising actual spraying

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

Unknown

10. Route(s) of exposure.

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.)

Two staff members have come forward on Wednesday April 22nd 2015 after it was announced that a pesticide was used. (age) male (work title) described 'slight headache, lightheaded.' Symptoms disappeared by evening. No medical attention sought. (age) male kitchen manager cleared kitchen area of students, but was present during spraying (Friday April 10). Left after spraying was completed with 'slight headache, lightheaded.' This staff member worked that night at his other job in the community felling fine, 'after getting some fresh air.' Ministry of Labour arrived Wednesday April 22, 2015 to investigate after receiving 'an anonymous complaint that pesticide had been sprayed in the kitchen area and workers were present.' (city) Public Health visited on Thursday April 23 2015. School Board personnel - Health and Safety, Superintendent, (name) Principal, (name) Principal and others have been involved in the investigation as well.

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

• Gastrointestinal System
  • Symptom - Nausea
  • Specify - felt sick to stomach
  • Symptom - Anorexia

• Respiratory System
  • Symptom - Difficulty Breathing

• Nervous and Muscular Systems
  • Symptom - Dizziness
  • Symptom - Headache

4. How long did the symptoms last?

>1 wk <=1 mo / > 1 sem < = 1 mois

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

Occupational

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

Contact with treated area

Amount of time between application and contact 4

Hour(s) / Heure(s)

What was the activity? Cleaning kitchen where pesticide was sprayed

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

Unknown

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

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

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.)

(Age) female (work title) cleaned kitchen area 4 hours after pesticide application. States that on 'Friday April 17 2015' had a hard time breathing that evening around 12 AM. Monday April 20 2015 had to lie down for an hour felt sick to stomach, dizzy and headache. Tuesday and Monday had no appettite upset stomach. 'This person visited doctor on Thursday April 23 2015 and has been issued three days off work. Details for documentation forthcoming. (age) (work title) cleaned kitchen four hours after the Friday (April 10) application of the pesticide by (company name). Ministry of Labour arrived Wednesday April 22, 2015 to investigate after receiving 'an anonymous complaint that pesticide had been sprayed in the kitchen area and workers were present.' (city) Public Health visited on Thursday April 23 2015. School Board personnel - Health and Safety, Superintendent, (name) Principal, (name) Principal and others have been involved in the investigation as well.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.