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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-0894

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. 31130      PMRA Submission No.       EPA Registration No.


  • 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

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

I read the instructions on the label and on March 29, 2016 I opened all the windows and the balcony door in my apartment. I sprayed my apartment with Onguard, the pesticide came in a 2 L jug and I used almost the entire bottle. I sprayed all the baseboards, around the window frame, around the door frame, all my closets and closet doors, my kitchen cabinets, the bathroom vanity, the bedframes and some area rugs using the pail and spray that came with the pesticide when I bought it. I sprayed all my baseboards and behind the fridge.This took me approximately an hour to accomplish.

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.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.


  • Respiratory System
    • Symptom - Other
    • Specify - very strong odor
    • Symptom - Coughing
    • Symptom - Runny nose
  • Gastrointestinal System
    • Symptom - Sore throat
  • Eye
    • Symptom - Burning eye
    • Specify - burning sensation in my eyes
  • Nervous and Muscular Systems
    • Symptom - Coma
    • Symptom - Difficulty walking
    • Specify - hard time even walking
    • Symptom - Difficulty getting up
    • Specify - hard time standing
  • General
    • Symptom - Weakness
    • Specify - weakness when walking any distance
  • Respiratory System
    • Symptom - Difficulty Breathing
    • Specify - needs to sit to catch his breath after walking any distance
  • Eye
    • Symptom - Decreased vision
    • Specify - damaged muscle eyes

4. How long did the symptoms last?

>6 mos / > 6 mois

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

What was the activity? re-entry

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?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

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

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.)

I left my apartment at 9am due to a very strong odor but returned home at 7pm that night, watched TV, ate, and about 3 hours after being home, started coughing, having a runny nose, a sore throat and a burning sensation in my eyes. I took the container of pesticides with me when I went to the hospital after noticing something was wrong. I explained to the doctors what had happened, they called the poison control team, kept me overnight and discharged me in the morning. I was told that the chemical would give flu-live symptoms if I breathed in a certain amount. I was told my body was going to clean itself out in a couple of days and that I would be okay. Later that night, I felt that my situation was worsening so I went back to the hospital, stayed overnight, yet was discharged again in the morning. This event kept repeating itself from the dates of March 30 2016 through until April 4 2016. On April 4 2016, I called my friend to come over and when he walked in his question was `what is that funny smell?¿. I told him I had sprayed some pesticides 6 days ago. I figured everything was ok as I had not smelt anything since I was use to the smell being present. I had not remembered anything else from that night. My friend managed to put me in his car. Luckily the hospital is a 3-4 minute drive from my place. I ended up in intensive care where I was in a coma for 2 days and came to myself on April 6 2016. When I woke up, they moved me to a different ward of the hospital where I had to start physiotherapy because I had a hard time staying, standing or even walking for even just a few steps. The doctors wanted to know how far I had to walk from my street to get into my apartment. I told them about 50ft so they told me that If I managed to walk 150ft with the walker them I could go home. I need a walker to sit down when my breathing gets too fast for me to be comfortable. I was told not to push myself to hard. I was back in the hospital on April 17-19th,30th, August 6,2016, January 3-6,8th,18th,19th,20th,29th,30th and February 8-13th 2017. My condition is worsening. I still walk with a walker because after 5-10 minutes I feel weak and need to sit down to catch my breath before I can begin again. Medications prescribed April 2016: Azithroycin 250/500mg tablet, Moxifloxicain GCL 400mg tablet, Apoprednisone ¿ 50mg for 8 days and then 5mg for 30 days, Totratropium 250mg/ml tablet, D.suvastin 81mg, Lorazepam 1mg, Bricanlih 0.5mg, Ventolin 100mg, Salbutomal 6mg, Symbicourt- 200mg, Spirvia capsule 18mg, Advair 250mg. Medications prescribed January 2017: Corticosteroin Injection, Instant IV, Amitriptylin ¿ 25mg, Apoprednison ¿ 50 mg for 5 days, Jamp Mocifoxain ¿ 400mg for 9 days, Prednison ¿ 90 tablets, Spirva ¿ 18mg, Veutolin 100mg Salbutamole Sulfate, Advair 250mg, Teva-Iptatropium Bromide 250 mg.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.