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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-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. 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.
