Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-4189

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.

Unknown

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. 28121      PMRA Submission No.       EPA Registration No.

Product Name: BLACK FLAG FOG INSECTICIDE

• Active Ingredient(s)
  • PROPOXUR

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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: Pub. Area - Outdoor/Zone publique - ext

Préciser le type: restaurant patio

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

A tenant of a building in (city) has a window above a restaurant. Last week, she had the window open and the owner of the restaurant used Black Flag Insecticide (PCPA 28121) on the patio to control mosquitoes. The fog entered her apartment along with smoke from a smoker on the 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

• Gastrointestinal System
  • Symptom - Nausea
  • Symptom - Vomiting

4. How long did the symptoms last?

>2 hrs <=8 hrs / > 2 h < = 8 h

5. Was medical treatment provided? Provide details in question 13.

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Drift from the application site

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.)

The woman has asthma and so the smoke can impact her. This time, she suffered severe nausea and vomited. She was treated and released from the local Emergency Room. Symptoms lasted a few hours and as of last report, she has no lasting effects. The landlord (restaurant owner) and tenant have worked this out; the tenant will be notified before any future fogging and the window will be upgraded.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.