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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2358

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.


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. 27428      PMRA Submission No.       EPA Registration No.

Product Name: Demand CS insecticide

  • Active Ingredient(s)

PMRA Registration No. 30075      PMRA Submission No.       EPA Registration No.

Product Name: Bedlam Insecticide

  • 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).

Caller reports that she lives in a residential home that has been converted into two apartment units. She lives in the basement apartment and there is a tenant living in the other unit above her. The main floor unit has a bed bug infestation and XXXX was on site on November 2, 2013 and applied Demand CS and Bedlam pesticides. The caller advised that she was informed by her landlord that she did not need to vacate the premises during the pesticide application and she spoke with the exterminator (XXXXX) before he applied the pesticides on the morning of November 2 advising him that she would be in the basement sleeping.

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.


2. Demographic information of data subject

Sex: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • Skin
    • Symptom - Hives
    • Symptom - Rash
  • General
    • Symptom - Other
    • Specify - allergic reaction
  • Skin
    • Symptom - Burning skin
    • Symptom - Cracked skin
    • Symptom - Skin sensitivity
    • Specify - any cold or heat against her skin was extremely painful

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

What was the activity? upper floor of house treated, subject lives in basement


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.)

The application occurred and she reportedly reacted to the products and required medical treatment for both epidermal and respiratory reactions. The bed bug infestation requires further treatment and the exterminator is to be on site tomorrow. The caller is concerned as medical personnel advised her that she is now very sensitive to these two products and further exposure to them could be very harmful to her. She is also concerned about the safety practices of the exterminator. Caller stated that she broke out in a rash when she woke up from her sleep on Saturday afternoon and was covered in a blotchy rash on most of her body, specifically her face. Another woman staying in the basement apartment with XXXXX was also reportedly affected with similar symptoms, but she ceased experiencing any adverse effects by Saturday evening. XXXXX stated by Saturday night she had broken out in hives, and had a significant rash on most of her body. At this time, XXXXX decided to go to the emergency department of the XXX Hospital. At htis time, she was advised by the attending doctor that she was having an allergic reaction. They could not state exactly what the issue was with the reaction, but the hospital did state that it was very possibly due to the pesticides. A prescription was written for XXXXX for Prednisone, 30mg/day for 5 days, and also for Benadryl, 50mg 3 x /day for five days. On November 5, 2013, XXXXX again went to the XXX Hospital as her symptoms had worsened to the point of what she described as "extreme skin sensitivity". XXXXXstated that by this point her skin was burning and dry-cracking to the point where any cold or heat against her skin was extremely painful, including evenr breath on her face. Also, XXXXX states that her tear ducts were becoming very dry and would not water when in the wind, or crying, etc. During this visit to the hospital emergency department, XXXXX was prescribed Predisone, 50mg/day for 5 days; hydroxyzine, 10mg 3 x / day for 10 days; and also was advised to only use Aveno soap and hand cream. Today, November 13, 2013, XXXXX once again met with the pest technician. XXXXX noticed he arrived at her place of residence this morning at approx. 09:00 hrs. XXXXX stated to XXXXX that he was not planning to use pesticides this time, that he was only going to use steam during this treatment, again on the 3rd floor of the house. XXXXX stated she saw XXXXX taking a box of chemicals inside the house and she asked him if he was going to take them inside. XXXXX stated he was not planning on using them, so XXXXX asked him to leave them outside the house. XXXXX then stated to XXXXX that he beleived her medical issues were between her and her doctor, and that he couldn't see how spraying one room on the third floor would affect her. XXXXX stated that XXXXX completely dismissed the pesticides as having anything to do with her rash. XXXXX stated that XXXXX returned to his truck and picked up a steamer unit, and advised her that only water was in it. However, as XXXXX re-entered the house, he stated that there was "a change in plans". XXXXX believes he was going use the pesticides again with her in the house. XXXXX stated that the house is a 3-storey older home (ie. 1940's) and has a single furnace / HVAC system with all of the ventilation exchanged between all rooms in the home. The basement does not have a separate HVAC system from the rest of the house.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.