Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-6792

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: ALBERTA

6. Date incident was first observed.

15-NOV-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. 32524      PMRA Submission No.       EPA Registration No.

Product Name: TEMPRID SC

• Active Ingredient(s)
  • BETA-CYFLUTHRIN
  • IMIDACLOPRID

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PMRA Registration No. 11540      PMRA Submission No.       EPA Registration No.

Product Name: 3610 ULV INSECTICIDE

• Active Ingredient(s)
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
  • PIPERONYL BUTOXIDE
  • PYRETHRINS

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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: 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 entire apartment building (xxx) was sprayed by a company called (name) on Nov 12 &13, 2019 I initially attempted to move back on Friday Nov 15 (48 hours post spray - (name) told tenants it was safe to return 6-24 hours post spray). The smell and fumes in the common areas of the building were horrible and worse in my apartment. In spite of having windows open in my suite I was unable to last in my apartment due to severe headaches, nausea, eye and throat irritation (in spite of wearing a respirator mask). So I left the building. I was out of the apartment for the next 12 days except for short stops to open windows when weather was warm, check mail etc. I attempted to stay in my apartment overnight on Nov 26 & Nov 27. I experienced severe headaches both of the following days as a result which got increasingly worse after staying in the building on the second night. I again was forced to find alternate accommodation and haven't been able to move back since. I was in my apartment for 3 hours last night (Dec 5) and left due to a headache. After sleeping at a different location on Nov 28 - my headaches resolved by the following day. Please note, I am not someone who gets headaches regularly nor do I have environmental sensitivities. I am very healthy individual who normally has no health concerns.

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

• Gastrointestinal System
  • Symptom - Nausea

• Nervous and Muscular Systems
  • Symptom - Headache
  • Specify - severe

• Respiratory System
  • Symptom - Irritated throat

• Eye
  • Symptom - Irritated eye

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

Non-occupational

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

Contact with treated area

Amount of time between application and contact 2

Day(s) / Jour(s)

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

Respirator

10. Route(s) of exposure.

Respiratory

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: Severe headaches (initial re-entry into my apartment was 48 hours post spray). It is over 3 weeks post spray and I'm still getting moderate to severe headaches depending on length of stay in my apartment. Nausea Eye irritation Throat irritation Symptoms intensify if window of the apartment is closed and symptom intensify with increased duration of time in the apartment (regardless of if windows are open or not). Symptoms intensify if I am closer to surfaces that were sprayed (ie when squatting down to tie shoes - strong chemical smell from baseboards was noted and intensification of headaches). Symptoms resolve with leaving the building - time required for symptoms to resolve relate to the time that I spent in the building. Symptoms improve if I wear an N95 mask while in the building, symptoms improve some with windows being open - however they are still present/ limit time I can spend in the apartment.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.