Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2018-4101
2. Registrant Information.
Registrant Reference Number: 5911739
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.
10-APR-18
5. Location of incident.
Country: CANADA
Prov / State: NEWFOUNDLAND
6. Date incident was first observed.
01-MAR-18
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: Green Earth Homecare Bed Bug Travel Spray
- 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: 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).
Caller reports he used the product yesterday on his bed, mattress, sheets, and chair. He said he did ventilate a little after use. He can still smell a faint odor now. He began to have symptoms this morning.
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: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Respiratory System
- Symptom - Nasal congestion
- General
- Symptom - Chemical taste in mouth
- Symptom - Other
- Specify - sore nose
- Symptom - Other
- Specify - throat irritation
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)
Contact with treated area
What was the activity? sleeping
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
Respiratory
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.)
03/01/18 19:57: Caller reports he used the product yesterday on his bed, mattress, sheets, and chair. He said he did ventilate a little after use. He can still smell a faint odor now. He began to have symptoms this morning. O. Symptoms co: congestion bad taste Symptoms: Nasal congestion. Recomendation: 1) Move to fresh air environment. 2) Ventilate indoor areas with fresh air until all odor has dissipated. 3) Thoroughly wash skin with mild soap and water, lather skin 3 times. 4) Inhale steam from shower. If difficulty breathing, persistent cough, or prolonged symptoms occur, seek medical attention with HCP. Will CB 2 days for f/u. 03/02/18 14:32 CB performed to number provided. Caller states his SX continue to improve. Today his throat is dry and nose is sore. O: Throat irritation, sore nose R: If SX persist or worsen, seek medical evaluation. Call back with questions/concerns.
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.