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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2018-4123
2. Registrant Information.
Registrant Reference Number: 5883773
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.
12-JAN-185. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
02-DEC-17Product 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. 26679 PMRA Submission No. EPA Registration No.
Product Name: HomeCare Bed Bug & Crawling Insect Killer Dust
- Active Ingredient(s)
- SILICON DIOXIDE (PRESENT AS 100% DIATOMACEOUS EARTH) - FRESH WATER FOSSILS
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).
all over the houseTo 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: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Gastrointestinal System
- Symptom - Dry mouth
- Respiratory System
- Symptom - Other
- Specify - Dry sinuses
4. How long did the symptoms last?
>1 wk <=1 mo / > 1 sem < = 1 mois
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? occupying the house
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.
Respiratory
11. What was the length of exposure?
>1 wk <=1 mo / > 1 sem < = 1 mois
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 had used HomeCare Bed Bug Crawling Insect Killer Dust throughout his entire home. He thinks he may have used to much of the product. States that he and his family are suffering from dry mouth and dried mucus from sinus. Caller read that crystalline silica is a carcinogen and is now worried about cancer from inhaling the product. Caller, his wife, and 4mo child live . R: Instructed caller to cleanup the areas and discontinue use of the product. Caller state that he has cleaned the dust up and ventilated. If SXS persist, may be necessary to seek medical attention. Went over issues of cancer from product. Not expected to develop from exposure to the product. Would be more likely in factory/quarry worker inhaling the fine particulates daily for years, than for his family to gain it from a 2 week exposure
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.
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: Female
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Gastrointestinal System
- Symptom - Dry mouth
- Respiratory System
- Symptom - Other
- Specify - Dry sinuses
4. How long did the symptoms last?
>1 wk <=1 mo / > 1 sem < = 1 mois
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? occupying the house
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.
Respiratory
11. What was the length of exposure?
>1 wk <=1 mo / > 1 sem < = 1 mois
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 had used HomeCare Bed Bug Crawling Insect Killer Dust throughout his entire home. He thinks he may have used to much of the product. States that he and his family are suffering from dry mouth and dried mucus from sinus. Caller read that crystalline silica is a carcinogen and is now worried about cancer from inhaling the product. Caller, his wife, and 4mo child live . R: Instructed caller to cleanup the areas and discontinue use of the product. Caller state that he has cleaned the dust up and ventilated. If SXS persist, may be necessary to seek medical attention. Went over issues of cancer from product. Not expected to develop from exposure to the product. Would be more likely in factory/quarry worker inhaling the fine particulates daily for years, than for his family to gain it from a 2 week exposure
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.
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: Unknown
Age: <=1 yr / < = 1 an
3. List all symptoms, using the selections below.
System
- Gastrointestinal System
- Symptom - Dry mouth
- Respiratory System
- Symptom - Other
- Specify - dry sinuses
4. How long did the symptoms last?
>3 days <=1 wk / >3 jours <=1 sem
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? occupying the house
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.
Respiratory
11. What was the length of exposure?
>3 days <=1 wk / >3 jours <=1 sem
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 had used HomeCare Bed Bug Crawling Insect Killer Dust throughout his entire home. He thinks he may have used to much of the product. States that he and his family are suffering from dry mouth and dried mucus from sinus. Caller read that crystalline silica is a carcinogen and is now worried about cancer from inhaling the product. Caller, his wife, and 4mo child live . R: Instructed caller to cleanup the areas and discontinue use of the product. Caller state that he has cleaned the dust up and ventilated. If SXS persist, may be necessary to seek medical attention. Went over issues of cancer from product. Not expected to develop from exposure to the product. Would be more likely in factory/quarry worker inhaling the fine particulates daily for years, than for his family to gain it from a 2 week exposure
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.
