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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-4530

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: UNKNOWN

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: Dragnet

  • 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: 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: My apartment was treated for cockroaches in the beginning of August. When I returned home, after the time they told me to, I started cleaning as instructed. The apartment still smelled very strong of insecticide even though the windows were open during treatment which was at 11:30 am and I returned home at 8:30 pm. I called the company and they told me to let it air out for the night and sleep somewhere else as I have a x old baby. Before I left I cleaned the floors and washed down the eating areas as instructed. When I was cleaning the floors I moved a bag that was in the middle of the kitchen floor. When I picked it up it was completely soaked in pesticed. It accidentally touched my leg and I mopped underneath and didn't think much of it after that.

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: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • Skin
    • Symptom - Red skin
    • Symptom - Burning skin

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: Later that evening my leg got all red and started burning. I had a shower around 11:30 pm and the burning got worse. I called poison control and she couldn't tell me much as she didn't know what pesticide was used but said to just watch it over night. The next morning I contacted the company to ask which pesticide they use and she wouldn't tell me until I told her about the bag and said that only the baseboards were sprayed. When I told her about my leg she told me they use dragnet. I called back poison control and they said not to worry about any toxic effects. The next day I through out the bag and all the contents as it reaked of pesticide. Since then I have cleaned and mopped and my apartment still smells of pesticide.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.