Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-1727

2. Registrant Information.

Registrant Reference Number: 5991519

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-NOV-18

5. Location of incident.

Country: CANADA

Prov / State: UNKNOWN

6. Date incident was first observed.

18-OCT-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)

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PMRA Registration No. 26679      PMRA Submission No.       EPA Registration No.

Product Name: Green Earth HomeCare Bed Bug and Crawling Insect Killer Dust

• Active Ingredient(s)
  • SILICON DIOXIDE (PRESENT AS 100% DIATOMACEOUS EARTH) - FRESH WATER FOSSILS

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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).

applied some Green Earth HomeCare Bed Bug and Crawling Insect Killer Dust in their home on the bed, couches and around the home.

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: Female

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Difficulty Breathing
  • Symptom - Coughing

• Cardiovascular System
  • Symptom - Tachycardia

• Nervous and Muscular Systems
  • Symptom - Headache

4. How long did the symptoms last?

Unknown / Inconnu

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)

Contact with treated area

What was the activity? entered the space treated

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?

>24 hrs <=3 days / >24 h <=3 jours

12. Time between exposure and onset of symptoms.

>24 hrs <=3 days / >24 h <=3 jours

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 states that her son and daughter applied some Green Earth HomeCare Bed Bug and Crawling Insect Killer Dust in their home on the bed, couches and around the home. By Sunday early evening they were in the ER respiratory distress, headaches,coughing and their heart rate was very high. Treated and released Advised not to back to the house and need to FU with physician They both were wearing masks when vacuuming up the product as directed. Caller wants this product off the market and wants to speak to the company Symptoms: Coughchoke Mild respiratory distress Respiratory pain Headache Other Patient #2 Symptoms: Coughchoke Mild respiratory distress Respiratory pain Headache Other R. Transferred to CS to leave a message No medical recommendations given caller's son daughter were both treated and released

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.

Other

2. Demographic information of data subject

Sex: Male

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

3. List all symptoms, using the selections below.

System

• Cardiovascular System
  • Symptom - Tachycardia

• Respiratory System
  • Symptom - Difficulty Breathing

• Nervous and Muscular Systems
  • Symptom - Headache

• Respiratory System
  • Symptom - Coughing

4. How long did the symptoms last?

Unknown / Inconnu

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)

Contact with treated area

What was the activity? entered treated area

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?

>24 hrs <=3 days / >24 h <=3 jours

12. Time between exposure and onset of symptoms.

>24 hrs <=3 days / >24 h <=3 jours

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 states that her son and daughter applied some Green Earth HomeCare Bed Bug and Crawling Insect Killer Dust in their home on the bed, couches and around the home. By Sunday early evening they were in the ER respiratory distress, headaches,coughing and their heart rate was very high. Treated and released Advised not to back to the house and need to FU with physician They both were wearing masks when vacuuming up the product as directed. Caller wants this product off the market and wants to speak to the company Symptoms: Coughchoke Mild respiratory distress Respiratory pain Headache Other Patient #2 Symptoms: Coughchoke Mild respiratory distress Respiratory pain Headache Other R. Transferred to CS to leave a message No medical recommendations given caller's son daughter were both treated and released

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.