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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-3263

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.


4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA


6. Date incident was first observed.


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.


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

Product Name: unknown

  • Active Ingredient(s)

7. b) Type of formulation.

Other (specify)

Treated wood

Application Information

8. Product was applied?


9. Application Rate.

10. Site pesticide was applied to (select all that apply).

Site: Res. - Out Home / Rés - à l'

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

The following was reported: 3 years ago, we purchased pesticide treated posts and rails, treated with CCA, and put them up around a portion of our developed property. We did not know there were pesticides in this product and proceeded to pound posts, drill holes into rails, cut rail ends, and burn rail ends, all because we were never informed as to what pressure-treated meant and what the contents were. One month ago we purchased more posts and rails, to complete our project. that is where I noticed a label affixed to one bundle of rails that stated that the product contained arsenic, copper and chromium.

To be determined by Registrant

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


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.


  • Respiratory System
    • Symptom - Other
    • Specify - nostril inflammation
  • Ear
    • Symptom - Hearing loss
  • General
    • Symptom - Edema
    • Specify - swelling of hands and feet
  • Nervous and Muscular Systems
    • Symptom - Other
    • Specify - peripheral neuropathy
  • General
    • Symptom - Pain
    • Specify - Pain in feet upon rising
  • Nervous and Muscular Systems
    • Symptom - Other
    • Specify - Tingling in hands

4. How long did the symptoms last?

Unknown / Inconnu

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


6. a) Was the person hospitalized?


6. b) For how long?


7. Exposure scenario


8. How did exposure occur? (Select all that apply)

Contact with treated area

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)


10. Route(s) of exposure.


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.)

The following was reported: I began to experience inflammation in my nostrils, to the point that I suffered some hearing loss in one ear as it could not drain. I developed swelling in my hands and feet, peripheral neuropathy in my hands, and pain in my feet upon rising in the mornings. Most of these symptoms have lessened but have not gone away. I still suffer from tingling in my hands, inflammation in my nostrils, and some pain in my feet in the mornings.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.