Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-2601

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.

Human

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

Unknown

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. 24175      PMRA Submission No.       EPA Registration No.

Product Name: DRAGNET FT EMULSIFIABLE CONCENTRATE INSECTICIDE

• Active Ingredient(s)
  • PERMETHRIN

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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 caller indicated that signs were posted by the company on their neighbour's lawn, at x. Their other neighbour next to x apparently, also had applications done in the back of their yard. They clarified that the workers were wearing suits and were applying pesticides (caller used the word Fog) with a backpack device and a applicator that looked like a leaf blower.The caller recalled that the company was in the neighbourhood 3 times. In May 2018, June 13th, 8:43 a.m. and earlier this week.

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: Unknown

Age: >1 <=6 yrs / > 1 < = 6 ans

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Itchy eye

• Gastrointestinal System
  • Symptom - Sore throat

• Respiratory System
  • Symptom - Respiratory congestion
  • Specify - congestion NOS

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

Non-occupational

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

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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 and his wife reported that their three kids ages x, x and x have experienced itchy eyes, sore throat and congestion symptoms in the last week. The eldest child required the use of a puffer.None of the children have had past issues with allergies according to the parents. They also are experiencing an ant infestation in their home. When they called an exterminator about their ant problem, the exterminator asked if any pesticides were applied in the area recently, as ants are sensitive to pesticides and will move out of the area in question. It was then when they realized that their kids¿ symptoms and the ant problem coincided with recent pesticides applications completed by a company operating as x.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

This incident was reported to Ontario MOECC on 6July2018, who then contacted the extermination company for more information. The company specified they use a GPS driven mobile customer database system that documents the weather conditions at the specific location when they apply pesticides. They provided the following application dates for the area involved in the incident: May 30 -1:40 pm wind: 4; Direction NW; temperature 24, June 6 - 8:30 am wind: 4; Direction SE temperature 11, June 13 - 8:00 am wind: 2; Direction SW temperature 17, and July 3 - 10:00 am wind: 3; Direction SE temperature 25. Pesticide information provided by the company, PCP information, and MSDS sheets, were emailed to the reporter by MOECC. The reporter told MOECC that he received the information and was concerned that it appeared that the exterminator air applied the pesticide contrary to the instructions for the pesticide, Dragnet.

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

Age: >6 <=12 yrs / > 6 < = 12 ans

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Itchy eye

• Gastrointestinal System
  • Symptom - Sore throat

• Respiratory System
  • Symptom - Respiratory congestion
  • Specify - congestion NOS

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?

Unknown

7. Exposure scenario

Non-occupational

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

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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 and his wife reported that their three kids ages x, x and x have experienced itchy eyes, sore throat and congestion symptoms in the last week. The eldest child required the use of a puffer.None of the children have had past issues with allergies according to the parents. They also are experiencing an ant infestation in their home. When they called an exterminator about their ant problem, the exterminator asked if any pesticides were applied in the area recently, as ants are sensitive to pesticides and will move out of the area in question. It was then when they realized that their kids¿ symptoms and the ant problem coincided with recent pesticides applications completed by a company operating as x.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

This incident was reported to Ontario MOECC on 6July2018, who then contacted the extermination company for more information. The company specified they use a GPS driven mobile customer database system that documents the weather conditions at the specific location when they apply pesticides. They provided the following application dates for the area involved in the incident: May 30 -1:40 pm wind: 4; Direction NW; temperature 24, June 6 - 8:30 am wind: 4; Direction SE temperature 11, June 13 - 8:00 am wind: 2; Direction SW temperature 17, and July 3 - 10:00 am wind: 3; Direction SE temperature 25. Pesticide information provided by the company, PCP information, and MSDS sheets, were emailed to the reporter by MOECC. The reporter told MOECC that he received the information and was concerned that it appeared that the exterminator air applied the pesticide contrary to the instructions for the pesticide, Dragnet.

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Unknown

Age: >6 <=12 yrs / > 6 < = 12 ans

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Itchy eye

• Gastrointestinal System
  • Symptom - Sore throat

• Respiratory System
  • Symptom - Respiratory congestion
  • Specify - congestion NOS

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?

Unknown

7. Exposure scenario

Unknown

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

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.

Unknown / Inconnu

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 and his wife reported that their three kids ages x, x and x have experienced itchy eyes, sore throat and congestion symptoms in the last week. The eldest child required the use of a puffer.None of the children have had past issues with allergies according to the parents. They also are experiencing an ant infestation in their home. When they called an exterminator about their ant problem, the exterminator asked if any pesticides were applied in the area recently, as ants are sensitive to pesticides and will move out of the area in question. It was then when they realized that their kids¿ symptoms and the ant problem coincided with recent pesticides applications completed by a company operating as x.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

This incident was reported to Ontario MOECC on 6July2018, who then contacted the extermination company for more information. The company specified they use a GPS driven mobile customer database system that documents the weather conditions at the specific location when they apply pesticides. They provided the following application dates for the area involved in the incident: May 30 -1:40 pm wind: 4; Direction NW; temperature 24, June 6 - 8:30 am wind: 4; Direction SE temperature 11, June 13 - 8:00 am wind: 2; Direction SW temperature 17, and July 3 - 10:00 am wind: 3; Direction SE temperature 25. Pesticide information provided by the company, PCP information, and MSDS sheets, were emailed to the reporter by MOECC. The reporter told MOECC that he received the information and was concerned that it appeared that the exterminator air applied the pesticide contrary to the instructions for the pesticide, Dragnet.