Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-6013

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.

14-OCT-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)

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

Product Name: Tempo

• Active Ingredient(s)
  • CYFLUTHRIN
    • Guarantee/concentration 20 %

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7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Other / Autre

Préciser le type: Inside an elementary school

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

The following was reported: We found out October 23 through a school newsletter that all children's lockers and the baseboards at our chld's school, (name) in (city), Quebec had been sprayed with the chemical Permethrin (Bug-Tek, commercial name) on September 20, 2019. There was no newsletter or mass communication before the spraying event occurred on September 20. As far as we understand, the use of Permethrin is not allowed in schools in Quebec due to its effects if ingested by children. We suspect that the symptoms our son experienced are connected to touching something in his sprayed locker and then putting his fingers to his mouth (while eating) and to his eyes. In addition, this product was used again October 26 in the same places, lockers and baseboards (mentioned in the communication of October 23). Understandably, as we suspect that the first spraying of Permethrin allowed our son to ingest the pesticides and caused the symptoms outlined above, he will not be returning to this school October 28 when students return to class.

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.

2. Demographic information of data subject

Sex: Male

Age: >6 <=12 yrs / > 6 < = 12 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Vomiting

• General
  • Symptom - Lethargy

• Eye
  • Symptom - Burning eye

• General
  • Symptom - Abnormal behaviour
  • Specify - "oversensitive and hyper or nervous"

4. How long did the symptoms last?

>1 wk <=1 mo / > 1 sem < = 1 mois

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

Unknown

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)

Unknown

10. Route(s) of exposure.

Skin

Eye

Oral

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: Between September 14 and October 18 , (date not known), our son came out of school rubbing his eyes and said they were burning. We asked if he meant itchy and he said no they are burning. At the time, we found it strange, but couldn't imagine what would cause something like that. The night of October 14, our son vomited violently all night, at least 8 times. After that, he did not eat for three days, was home from school 7 days, on the 8 tried to go to school was too fatigued to remain (was falling asleep). From October 14-24 he never bounced back from being sick, but has been exhausted every day after school (this is not typical). Although both of his parents cleaned up numerous bouts of vomiting without gloves, neither parent got sick in the least (this is not typical). We concluded that he had ingested something that we hadn't as it didn't seem to be a contagious virus.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.