Health Canada
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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2015-2380
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.
28-JUL-12Product 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)PMRA Registration No. PMRA Submission No. EPA Registration No.
Product Name: Unknown
- Active Ingredient(s)
- NAPHTHALENE
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).
My neighbour uses moth balls scattered around his garage to deter ground hogs from digging under his garage. The mothballs and their strong odor are about 15 feet from our window which is open in the summer and I am unable to sit outside as I get dizzy from the odor.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: Unknown
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
- Symptom - Dizziness
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)
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.)
The mothballs and their strong odor are about 15 feet from our window which is open in the summer and I am unable to sit outside as I get dizzy from the odor. I have approached my neighbour several times and he still insists on placing the moth balls there. We are also sleeping in our tent trailer about 40 feet from the moth balls. The neighbour recently went away and we removed the moth balls using gloves and a face mask and disposed of them at our waste depot. Is there some kind of written notice or information I could be leaving with my neighbour to read.
