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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2175

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


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. 25423      PMRA Submission No.       EPA Registration No.

Product Name: Final All Weather Blox

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


Other Units: blocks

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).

An (company) technician gave the rodenticides to my landlord who gave them to a tenant that lives below my apartment. I found around 11 blocks and several twisted up newspapers with other blocks crumbled inside. The pesticides were in an empty area under my bathroom floor that is on a higher level platform that also has plumbing pipes along the wall and has a murphy bed contained in a galvanized steel box. The poison was in a pile and not in a safety container.

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

3. List all symptoms, using the selections below.


  • Blood
    • Symptom - Bleeding
  • Gastrointestinal System
    • Symptom - Stomachache
    • Symptom - Stomach cramps
    • Symptom - Other
    • Specify - digestive and bowel problems
  • General
    • Symptom - Weakness
  • Skin
    • Symptom - Other
    • Specify - cuts not healing well

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)

Contact with treated area

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.)

I am very physically active and the symptoms of weakness were very obvious after around the early/middle of 2014. I am also a gardener/landscaper and I get cuts and scratches frequently, I had wondered why since then that they were not healing well and bleeding excessively. I would get a very upset stomach with severe cramps for hours with digestive and bowel problems.... I was increasingly getting weaker and I had totally stopped going to the gym were I went consistently 5-7 days/week for 5 years and had trouble lifting usually manageable tarps at work. In December I felt generally unwell. There was dermal exposure to the pesticides. While cleaning the apartment and washing the floors, etc... although I was mostly wearing gloves, I am sure that my hands were exposed to the poison when wringing out cloths...

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.