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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-0263

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.


4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.


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.


PMRA Registration No. 19480      PMRA Submission No.       EPA Registration No.

Product Name: Pro Boradust Insecticide Dust

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


10. Site pesticide was applied to (select all that apply).

Site: Res. - In Home / Rés. - à l'int. maison

Préciser le type: cracks and ducts

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

On October 1 2015, according to the complainant, the exterminator applied Pro Boradust Insecticide Dust (PCPA 19480) 'to fill crack and put in the duct work vents' to control german cockroaches. The duct work is shared throughout the home. The subject is home almost always. The roomate is often away and is not reporting impacts. The downstairs tenant is also not reporting impacts to the subject.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?


Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.


2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • Gastrointestinal System
    • Symptom - Dry mouth
    • Specify - mouth and throat
    • Symptom - Other
    • Specify - irritated tongue
    • Symptom - Irritated throat
    • Specify - throat and mouth
  • Respiratory System
    • Symptom - Other
    • Specify - dry and irritated nasal cavity
  • Gastrointestinal System
    • Symptom - Burning throat
    • Specify - burning sensation
    • Symptom - Other
    • Specify - blistering on back of throat
  • General
    • Symptom - Fatigue
  • Nervous and Muscular Systems
    • Symptom - Irritable
    • Symptom - Muscle weakness

4. How long did the symptoms last?

>1 mo and <= 2mos / >1 mois et < = 2mois

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


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


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)


10. Route(s) of exposure.


11. What was the length of exposure?

>1 mo <= 6 mos / > 1 mois < = 6 mois

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 complainant reports a number of symptoms and concerns including: dry (and irritated) mouth, tongue, throat, and nasal cavity, on and off burning sensation and soreness in throat (worsened when at home), and blistering on back of throat . Other symptoms experienced are fatigue, irritability, and muscle weakness. The complainant reports contacting the poison control centre and family physician. These symptoms are reported to have begun when the heating system was first used for the season, have lasted a couple of months. The symptoms are reported to have improved when the complainant left the apartment for the holidays; upon his return, the symptoms returned (although they may be less severe than before). In addition to the complainant, there are 3 other people who live in the house, a roommate in the same unit and a person downstairs who has custody of his (age) old son every other week. It was not determined if they are having symptoms simliar to the complainant. While the dust was initially place into the air ducts it was reported to be no longer present, the complainant is concerned that the dust is now distributed throughout his home.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.