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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-4655

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.

04-SEP-14

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. 24240      PMRA Submission No.       EPA Registration No.

Product Name: Max Force Roach Gel

  • Active Ingredient(s)
    • HYDRAMETHYLNON

PMRA Registration No. 13074      PMRA Submission No.       EPA Registration No.

Product Name: PRO Ant & Roach Dust

  • Active Ingredient(s)
    • PIPERONYL BUTOXIDE
    • PYRETHRINS

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).

Caller reports that personnel from Minto Apartments Ltd. are placing bait gels for ants and cockroaches in residents' apartments. Employees of Minto Apartments Ltd., who may not be licensed as structural exterminators, are placing "l" packets in Caller's apartment. Later details:Licensed structural applicators from were inside the apartment at the Site in May 2014. Only Max Force Roach Gel, PCP Registration Number 24240 and PRO Ant & Roach Dust, PCP Registration number 13074, were used at the tenant's apartment.

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 - Burning mouth
    • Symptom - Stomach pain
  • Respiratory System
    • Symptom - Difficulty Breathing

4. How long did the symptoms last?

>2 mos and <=6mos />2 mois et <=6mois

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.)

Caller stated that they have had difficulties with their health since May 5, 2014, when the last application of pesticides occurred. Symptoms included burning in the mouth, stomach pains and difficulty breathing.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.