Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2018-2789
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
Domestic Animal
4. Date registrant was first informed of the incident.
5. Location of incident.
Country: CANADA
Prov / State: QUEBEC
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)
PMRA Registration No. 27428
PMRA Submission No.
EPA Registration No.
Product Name: DEMAND CS INSECTICIDE
PMRA Registration No. 15255
PMRA Submission No.
EPA Registration No.
Product Name: DRIONE INSECTICIDE DUST
- Active Ingredient(s)
- PIPERONYL BUTOXIDE
- PYRETHRINS
- SILICA AEROGEL
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. - In Home / Rés. - à l'int. maison
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
The following was reported: On July 4, 2018 the landlord retained the services of x to apply a pesticide in the complainant's residence for the control of cockroaches. His wife and their 20 cats were present in the residence during the application. The cats were allegedly confined to a bedroom during the treatment and for a period of time following, but inspectors observed that there was no litter box in the bedroom. The exterminator claims to have made a perimeter treatment (a band 10 to 15cm wide) along the moldings of the apartment, except in the bedroom where the cats were confined. This information is consistent with the observations of the regional inspectors.
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: Female
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
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?
2
Day(s) / Jour(s)
Unknown
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Contact with treated area
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.
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.)
The following was reported: The complainant's wife had severe symptoms (coughing, headache, weakness and diarrhea) following the pesticide application, which required that she be hospitalized for a couple of days (July 11 - 12, 2018). According to the exterminator, the tenant (complainant's wife) entered the dwelling a few times for brief periods during the treatment, despite the exterminator having told her to remain outside. The tenant, who was treated by a Public Health doctor, had another episode of symptoms after having moved to a different apartment. The doctor questionned whether the symptoms could be related to pesticide exposure since the second episode occurred when there was no application of pesticides.
To be determined by Registrant
14. Severity classification.
15. Provide supplemental information here.
Subform III: Domestic Animal Incident Report
1. Source of Report
Other
2. Type of animal affected
Cat / Chat
3. Breed
Siamese
4. Number of animals affected
10
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
16. How was the animal exposed?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Exact number not known, but at least 10 of 20 cats belonging to the complainant died following application of pesticide(s) in the complainant's apartment. The cats were allegedly confined to a bedroom during and after the pesticide treatment, however regional inspectors noted that there was no litter box in the bedroom. Only one litter box was observed in the apartment (near the living room).
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Not Applicable
19. Provide supplemental information here
Possible autopsy results for 3 cats pending
Subform III: Domestic Animal Incident Report
1. Source of Report
Other
2. Type of animal affected
Cat / Chat
3. Breed
Siamese
4. Number of animals affected
10
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- General
- Symptom - Malaise
- Specify - Sick NOS
- Gastrointestinal System
- Symptom - Weight loss
- Symptom - Vomiting
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Unknown/Inconnu
16. How was the animal exposed?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Exact number not known, but at least 10 of 20 cats belonging to the complainant appeared unwell following application of pesticide(s) in the complainant's apartment. Regional inspectors noted that the surviving cats appeared emaciated, lethargic, and some were vomiting. The cats were allegedly confined to a bedroom during and after the pesticide treatment, however regional inspectors noted that there was no litter box in the bedroom. Only one litter box was observed in the apartment (near the living room).
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Not Applicable
19. Provide supplemental information here