Health Canada
Symbol of the Government of Canada
Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-1707

2. Registrant Information.

Registrant Reference Number: 6020377

Registrant Name (Full Legal Name no abbreviations): Premier Tech Ltd.

Address: 1 avenue Premier,

City: Riviere-du-Loup

Prov / State: Quebec

Country: Canada

Postal Code: G5R 6C1

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

12-FEB-19

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

04-JAN-19

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: Wilson One Shot Bed Bug Killer

  • 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).

sprayed entire contents of the can.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

No

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: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

  • Respiratory System
    • Symptom - Coughing
    • Symptom - Shortness of breath
    • Symptom - Irritated throat

4. How long did the symptoms last?

>1 mo and <= 2mos / >1 mois et < = 2mois

5. Was medical treatment provided? Provide details in question 13.

Yes

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.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

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.)

The caller sprayed an entire bottle of pesticide and inhaled fumes. She's been ill since. TOE: 2 months ago. The day she sprayed it she had throat irritation. Over the next 10 to 12 days, SX worsened into SOB, coughing and her lungs felt like they were closing. She's been seen by physicians and told each time that it was the flu. She now has inhalers and has episodes where she won't be able to breathe like she has asthma. Caller requests an SDS sheet be sent to her. Menopause estrogen and inhalers as needed NKA R: Recommend following up with physician and alerting them about exposure. Outcome unknown

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.