Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2346

2. Registrant Information.

Registrant Reference Number: x

Registrant Name (Full Legal Name no abbreviations): x

Address: x

City: x

Country: 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.

14-JUN-13

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. 17055      PMRA Submission No.       EPA Registration No.

Product Name: Naphthalene Moth Balls

• Active Ingredient(s)
  • NAPHTHALENE

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PMRA Registration No. 2525      PMRA Submission No.       EPA Registration No.

Product Name: Cedar scented moth ball packets

• Active Ingredient(s)
  • PARADICHLOROBENZENE

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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: Res. - Out Home / Rés - à l'ext.maison

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

The mothballs were spread June 13 or June 14, 2013. XXXXX reports mothballs are difficult to locate as hidden by plants in garden along shared property line between two houses. XXXXX reports when she attended site, strong moth ball odour that hurt her throat in garden closest to complainant's patio.

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: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Irritated throat
  • Specify - hurt her throat

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?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Other

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.

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.)

reported to Township that her neighbour has spread mothballs along a garden adjacent to the complainant's house and patio. Product could be either naphthalene or paradichlorbenzene.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.