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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2018-6414
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)PMRA Registration No. 28403 PMRA Submission No. EPA Registration No.
Product Name: PRESCRIPTION TREATMENT BRAND AVERT DRY FLOWABLE COCKROACH BAIT FORMULA
- Active Ingredient(s)
- ABAMECTIN
PMRA Registration No. 27897 PMRA Submission No. EPA Registration No.
Product Name: PRESCRIPTION TREATMENT BRAND AVERT 360A DUAL CHOICE ANT BAIT STATION
- Active Ingredient(s)
- ABAMECTIN
PMRA Registration No. 30533 PMRA Submission No. EPA Registration No.
Product Name: BORADICATE INSECTICIDE
- Active Ingredient(s)
- BORACIC ACID (BORIC ACID)
PMRA Registration No. 30075 PMRA Submission No. EPA Registration No.
Product Name: BEDLAMŽ INSECTICIDE
- Active Ingredient(s)
- D-PHENOTHRIN
- N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
PMRA Registration No. 22239 PMRA Submission No. EPA Registration No.
Product Name: CONTRAC BLOX KILLS RATS & MICE
- Active Ingredient(s)
- BROMADIOLONE
PMRA Registration No. 27428 PMRA Submission No. EPA Registration No.
Product Name: DEMAND CS INSECTICIDE
- Active Ingredient(s)
- LAMBDA-CYHALOTHRIN
PMRA Registration No. 24175 PMRA Submission No. EPA Registration No.
Product Name: DRAGNET FT EMULSIFIABLE CONCENTRATE INSECTICIDE
- Active Ingredient(s)
- PERMETHRIN
PMRA Registration No. 15255 PMRA Submission No. EPA Registration No.
Product Name: DRIONE INSECTICIDE DUST
- Active Ingredient(s)
- PIPERONYL BUTOXIDE
- PYRETHRINS
- SILICA AEROGEL
PMRA Registration No. 30375 PMRA Submission No. EPA Registration No.
Product Name: GREEN WAY ANT & ROACH BAIT GEL
- Active Ingredient(s)
- DISODIUM OCTABORATE TETRAHYDRATE
PMRA Registration No. 30173 PMRA Submission No. EPA Registration No.
Product Name: GREEN WAY ANT BAIT GEL
- Active Ingredient(s)
- BORAX
PMRA Registration No. 24240 PMRA Submission No. EPA Registration No.
Product Name: MAXFORCE ROACH
- Active Ingredient(s)
- HYDRAMETHYLNON
PMRA Registration No. 32275 PMRA Submission No. EPA Registration No.
Product Name: MAXFORCE IMPACT
- Active Ingredient(s)
- CLOTHIANIDIN
PMRA Registration No. 26565 PMRA Submission No. EPA Registration No.
Product Name: NIBAN GRANULAR BAIT C
- Active Ingredient(s)
- BORACIC ACID (BORIC ACID)
PMRA Registration No. 30788 PMRA Submission No. EPA Registration No.
Product Name: OPTIGARD ANT GEL BAIT INSECTICIDE
- Active Ingredient(s)
- THIAMETHOXAM
PMRA Registration No. 21573 PMRA Submission No. EPA Registration No.
Product Name: PRECOR EC EMULSIFIABLE CONCENTRATE
- Active Ingredient(s)
- (S)-METHOPRENE
7. b) Type of formulation.
Application Information
8. Product was applied?
Unknown
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Unknown / Inconnu
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
It was reported that the individual who has worked for (city) Community Housing Corporation since 2016, previously worked for other operators in both Canada and the UK. The individual is on limited duties and does not enter pesticide treated homes until 70 days have passed since the last residual treatment. It was reported that the individual admits to pesticide exposure with a previous employer many years ago. A list of all chemicals purchased/used by (city) Community Housing Corporation was provided.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: Male
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Gastrointestinal System
- Symptom - Other
- Specify - irritable bowel syndrome
- Blood
- Symptom - Dec. pseudocholinesterase enzyme actv
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
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)
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.)
It was reported that the individual, who had been experiencing "symptoms of an irritable bowl syndrome that has been an issue for years", underwent cholinesterase testing twice in the last couple of months. It was found that his cholinesterase levels were lower at the second test than at the first. It was reported that the individual "has tested positive for potential pseudocholinesterase".
