Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2018-4768
2. Registrant Information.
Registrant Reference Number: 9242018
Registrant Name (Full Legal Name no abbreviations): KUUS INC.
Address: 450 TAPSCOTT RD., UNIT 5, 6
City: SCARBOROUGH
Prov / State: ONTARIO
Country: CANADA
Postal Code: M1B 1Y4
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
24-SEP-18
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)
PMRA Registration No. 31946
PMRA Submission No.
EPA Registration No.
Product Name: MOSQUITO SHIELD PIACTIVE INSECT REPELLENT I -BOV
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: Personal use / Usage personnel
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Customer said she developed a bad rash from using PiACTIVE MS0022 BOV. The customer had previously used the PiACTIVE travel size pump spray MS0025 with no issues. She had used the product (MS0022) on her children and husband and they did not have a reaction. She asked if there were any ingredient differences between the two products. She was told that both products (MS0022 AND MS0025) have identical ingredients.
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
- Skin
- Symptom - Red skin
- Symptom - Rash
- Symptom - Inflammation of the skin
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?
No
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Application
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
11. What was the length of exposure?
<=15 min / <=15 min
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 outcome- the customer required prescription strength allergy meds to deal with the inflammation of the rash.
To be determined by Registrant
14. Severity classification.
Moderate
15. Provide supplemental information here.
The rash progressed daily without continued use, until prescription strength allergy meds were taken. The custtomer did not have any known allergies before this incident and the customer had used an identical product MS0025 without incident or reaction.