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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-4438

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

Prov / State: NOVA SCOTIA

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: Piactive insect repellant

  • Active Ingredient(s)

7. b) Type of formulation.


Application Information

8. Product was applied?


9. Application Rate.


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

Site: Personal use / Usage personnel

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

The following was reported: While at an outdoor event in the evening, I borrowed a friend's spray bottle of Piactive insect repellent. Others in my group had used it with no reaction and were pleased with its effectiveness and that it is not scented. I sprayed it on my hands to apply lightly to my face, neck & arms. The asthma / coughing started soon after but I did not connect it to the product right away. I was not aware of the skin symptoms until I arrived home a few hours later. I had been feeling quite warm even though the evening had cooled down. It did work to keep the bugs away but I will never use the product again. Thankfully I had the next day off from work to have time for the Benadryl to work. I went out to purchase calamine lotion and after a 3 minute walk to nearby pharmacy, the rash was more painful in the sunshine.

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: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.


  • Respiratory System
    • Symptom - Other
    • Specify - increased asthma symptoms
    • Symptom - Coughing
  • Skin
    • Symptom - Pain
    • Specify - stinging
    • Symptom - Red skin
    • Symptom - Rash
    • Symptom - Burning skin
    • Symptom - Photosensitivity

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)


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: Increased asthma symptoms, coughing without clearing even after use of rescue puffer. Few hours later experienced heat and burning all areas where product applied. Looked as if very bad sunburn. Stinging rash on face, neck and arms. Worse on face and neck. Benadryl tablets and calamine lotion eased symptoms. Occurred during hotter weather period and uncomfortable. 36 hours or so before skin started to heal. Skin felt extra sensitive to the sun.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.