Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-1353

2. Registrant Information.

Registrant Reference Number: 2017320

Registrant Name (Full Legal Name no abbreviations): KUUS INC.

Address: 450 TAPSCOTT RD., UNIT 5, 6

City: TORONTO

Prov / State: ONTARIO

Country: CANADA

Postal Code: M1B 1Y4

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

27-JAN-17

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

10-AUG-16

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. 28584      PMRA Submission No.       EPA Registration No.

Product Name: KNOCK DOWN MAX FLYING INSECT KILLER (1.0 PYRETHRIN FROM CHRYSANTHEMUM

• Active Ingredient(s)
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
  • PIPERONYL BUTOXIDE
  • PYRETHRINS

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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: Res. - Out Home / Rés - à l'ext.maison

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

The incident occurred due to the fact that the exterminator did not use the product in accordance with the directions on the label.

To be determined by Registrant

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

No

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Burns (superficial)

• Ear
  • Symptom - Tinnitus
  • Specify - buzzing in ears

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

Unknown

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

Other

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.

Skin

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

As per the statement from the exterminator - (first name last name): first name suffered from buzzing in his ears and Mr. (name)suffered from a burn to his leg. I believe both Mr. (name) and (first name last name) went to the hospital.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

For pt 14. - I am not aware of the severity classification, but because it is a mandatory field, I am submitting it as 'minor'. This information can be received from the exterminator and company that did the extermination. (company name), (first name last name). Please note that (first name last name) has additional information that I have sent to him regarding this incident. We are of the opinion that the root cause of the incident was that the exterminator misused the product, did not follow the label directions, precautions and uses as listed on the label.

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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Ear
  • Symptom - Tinnitus
  • Specify - buzzing in ears

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

Occupational

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

Other

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.

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

As per the statement from the exterminator - (first name last name): first name suffered from buzzing in his ears and Mr. (name)suffered from a burn to his leg. I believe both Mr. (name) and (first name last name) went to the hospital.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

For pt 14. - I am not aware of the severity classification, but because it is a mandatory field, I am submitting it as 'minor'. This information can be received from the exterminator and company that did the extermination. (company name), (first name last name). Please note that (first name last name) has additional information that I have sent to him regarding this incident. We are of the opinion that the root cause of the incident was that the exterminator misused the product, did not follow the label directions, precautions and uses as listed on the label.