Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-7258
2. Registrant Information.
Registrant Reference Number: 5827761
Registrant Name (Full Legal Name no abbreviations): Sure-Gro IP Inc.
Address: 1900 Minnesota Crt
City: Mississauga
Prov / State: Ontario
Country: Canada
Postal Code: L5N 3C9
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
15-AUG-17
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
08-JUL-17
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. 30158
PMRA Submission No.
EPA Registration No.
Product Name: Wilson One Shot Bed Bug Killer
- Active Ingredient(s)
- D-PHENOTHRIN
- TETRAMETHRIN
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: Unknown / Inconnu
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
unknown
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.
Data Subject
2. Demographic information of data subject
Sex: Male
Age: >64 yrs / > 64 ans
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Edema
- Symptom - Erythema
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
No
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)
Application
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.
Skin
11. What was the length of exposure?
>8 hrs <= 24 hrs / >8 h <= 24 h
12. Time between exposure and onset of symptoms.
>8 hrs <=24 hrs / > 8 h < = 24 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.)
07/08/17 13:31: The caller was spraying the product when the wind blew some back onto his arm and leg. TOE: 1 day ago. He did not wash the area until today. There's a red splotch on his arm that's swollen where product was. Incontinence, thyroid probs Synthroid, Trovesa NKA O: Redness/erythema, edema A: Acute adult dermal Wilson One Shot Bed Bug Killer SX R: Wash contaminated skin and hair 3 times with soap and water. Pat dry. May apply vitamin E oil for minor irritation. If symptoms persist or worsen, a healthcare evaluation may be indicated. CB scheduled. 07/08/17 19:01: CB to number given phone number, unable to speak with anyone. Left message with case number and telephone number for outcome.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified.