Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-7277
2. Registrant Information.
Registrant Reference Number: 5855806
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.
02-OCT-17
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
09-SEP-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. 26201
PMRA Submission No.
EPA Registration No.
Product Name: Wilson Jet Foam Wasp & Hornet Killer
- Active Ingredient(s)
- D-TRANS ALLETHRIN
- N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
- PERMETHRIN
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).
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.
Other
2. Demographic information of data subject
Sex: Male
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Eye
- Symptom - Irritated eye
- Symptom - Conjunctivitis
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?
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.
Eye
11. What was the length of exposure?
<=15 min / <=15 min
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.)
Caller states her husband had sprayed Wilson Jet Foam Wasp Hornet Killer at a nest outside and had gotten the into his eyes. Irrigated eye with water 10 minutes went into walk in clinic and was told to go to an ER because the clinician could find no information on the product. TOE 3 hours no contacts both gh, nka O: SXS redness, irritation A: Acute, Adult, Ocular, Wilson Jet Foam Wasp Hornet Killer, SXS R: Flush eye(s) with comfortable temperature water for 10 15 minutes. Do not add any medicated eye drops after the irrigation is completed. Allow eyes to rest for 10 minutes using a cold compress over closed eyes. If SXS persist and/or new SXS develop, such as changes in vision or FOS develops, seek immediate medical attention.
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.