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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-2382

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.

01-NOV-12

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)

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

Product Name: DRAGNET FT EMULSIFIABLE CONCENTRATE INSECTICIDE

  • Active Ingredient(s)
    • PERMETHRIN

PMRA Registration No. 30032      PMRA Submission No.       EPA Registration No.

Product Name: KNOCK DOWN PROFESSIONAL KD120P FLYING & CRAWLING INSECT KILLER

  • Active Ingredient(s)
    • PIPERONYL BUTOXIDE
    • PYRETHRINS

PMRA Registration No. 21573      PMRA Submission No.       EPA Registration No.

Product Name: PRECOR EC EMULSIFIABLE CONCENTRATE

  • Active Ingredient(s)
    • (S)-METHOPRENE

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. - 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).

The owner (XXXXX) called the Ministry that their tenant at XXXXXX and the tenant's friend experienced symptoms following a structural extermination to kill fleas in the home. the pesticides application occurred on October 20, 2012. A licensed structural applicator applied the pesticides to the baseboards at the Site. The application of pesticides was only to the baseboards (or mopboards). There was no aerial application of pesticides inside the house.

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

  • Gastrointestinal System
    • Symptom - Other
    • Specify - lost taste in mouth

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)

Contact with treated area

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.

Unknown

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 impacted individuals visited a doctor and he recommended that the house be cleaned. One of the individuals allegedly lost taste in their mouth.the tenant noted that they felt ill, commening on Tuesday, October 23, 2012. The tenant sought medical attention.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.