Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-1758

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.

Environment

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

20-OCT-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. 27227      PMRA Submission No.       EPA Registration No.

Product Name: OFF! POWERPAD MOSQUITO LAMP

• Active Ingredient(s)
  • D-CIS,TRANS-ALLETHRIN
    • Guarantee/concentration 21.97 %

---

7. b) Type of formulation.

Other (specify)

Lamp

Application Information

8. Product was applied?

Unknown

9. Application Rate.

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 product was placed on the back patio balcony in Summer 2017.

To be determined by Registrant

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

Unknown

Subform IV: Environment (includes plants insects and wildlife)

1. Type of organism affected

Herbaceous Plants / Plante herbacée

2. Common name(s)

Unknown

3. Scientific name(s)

Unknown

4. Number of organisms affected

5. Description of site where incident was observed

Fresh water

Terrestrial

Residential

Salt Water

6. Check all symptoms that apply

Abnormal flower quality or number

Death

7. Describe symptoms and outcome (died, recovered, etc.).

Upon placing the product (OFF! POWERPAD MOSQUITO LAMP) on the back patio balcony, it was observed that plants and flowers (6 to 9) were weakened and indicated signs of not fresh or recovery. In few days after, several flowers in flower-pots died and remained in dry condition with no recovery. It was reported the product caused a death to several flowers in an area of 0.5 m around. The product was used anymore as a result of this incident. Date of incident is reported as not accurate. Reporter reports that it raises a concern what is effect of fumes and chemical of this product for long term exposure to human beings and animals if get in the contact or inhaled. The concern is also about possible pollution of air and transfer of chemical reactions to surrounded plants. This is the second example of aggressive impact of OFF products and I seek for Health Canada guidance to confirm if the OFF products are in compliance with the chemical substance regulations and that it declares no possible negative impact on human being. The product does not mention any negative impact on environment but it cause a death to several flowers and further effect on nature / human being to be confirmed.

8. a) Was the incident a result of (select all that apply)

Unknown

8. b) i) How many times has the product been applied this year?

Unknown

8. b) ii) What was the date of the last application?

Unknown

9. Did it rain

9. a) During application?

Unknown

9. b) Up to 3 days after application?

Unknown

10. a) Was there a buffer zone?

Unknown

10. b) What type?

10. c) What was the size of the buffer zone?

11. a) Were environmental samples collected and analysed?

No

To be determined by Registrant

12. Severity classification (if there is more than one possible classification, select the most severe)

13. Please provide supplemental information here