Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2019-3334
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: QUEBEC
6. Date incident was first observed.
04-JUL-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.
PMRA Submission No.
EPA Registration No.
Product Name: Temprid
- Active Ingredient(s)
- BETA-CYFLUTHRIN
- IMIDACLOPRID
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).
The following was reported/Ce qui suit a été rapporté: Comme agente d'intervention à la salubrité j'accompagne les exterminateurs dans les logements à traiter. Puisque j'ai une sensibilité accrue au produit je ne peux être dans le logement même avec un masque lors de l'application. Pendant que j'étais en intervention avec la locataire, le technicien a débuté le traitement lorsque nous étions encore dans le logement à 5 mètres. J'ai sorti rapidement quand j'ai pris connaissance qu'il appliquait le produit. J'ai donc été exposée brièvement aux vapeurs et je n'avais pas mon masque à ce moment. Mon visage a immédiatement commencé à engourdir.
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
- Nervous and Muscular Systems
- Symptom - Numbness
- Specify - right side of face/visage côté droit
- General
- Symptom - Discomfort
- Specify - area of right eye/oeil droit
- Skin
- Symptom - Other
- Specify - feeling of thick skin near right eye/près de l'oeil droit, sensation que peau est épaisse
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?
Unknown
7. Exposure scenario
Occupational
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)
None
10. Route(s) of exposure.
Respiratory
11. What was the length of exposure?
<=15 min / <=15 min
12. Time between exposure and onset of symptoms.
<=30 min / <=30 min
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/Ce qui suit a été rapporté: Visage côté droit engourdi. Près de l'oeil, sensation que ma peau « est épaisse » inconfort à fermer mon oeil droit. Légère rougeur pendant quelques heures. Toutefois les autres symptômes peuvent persister sur plusieurs semaines . ( problème similaire et persistant lors de sa sortie sur le marché, j'avais consulté un médecin de la DSP). Symptômes apparaissent rapidement avec faible exposition.
To be determined by Registrant
14. Severity classification.
15. Provide supplemental information here.