Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-7026

2. Registrant Information.

Registrant Reference Number: 6081536

Registrant Name (Full Legal Name no abbreviations): PremierTech Ltd.

Address: 1, avenue Premier

City: Riviere-du-Loup

Prov / State: QC

Country: Canada

Postal Code: G5R 6C1

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

24-JUN-19

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

Unknown

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. 21936      PMRA Submission No.       EPA Registration No.

Product Name: Wilson AntOut Ant Killer Dust

• Active Ingredient(s)
  • SILICON DIOXIDE (PRESENT AS 100% DIATOMACEOUS EARTH) - FRESH WATER FOSSILS

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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).

Caller was using the product and she applied it in doors because she has a silver fish problem. She applied it on the edge of the rooms and in between door ways. She wears shoes inside and never steps directly on it. She has had the product out for about 1 to 1.5 months changing it once.

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: >12 <=19 yrs / >12 <=19 ans

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Coughing
  • Symptom - Chest congestion

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?

7. Exposure scenario

Non-occupational

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

Application

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.

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.)

She has had the product out for about 1 - 1.5 months, changing it once. She picked it up at that time. She stated that about a month of being out she started having some coughing, lung irritation and some rattling in her lungs when she takes a deep breath. Advised to seek medical attention due to symptoms. Also recommended to keep hydrated and move to fresh air environment. Indoor areas should be ventilated with fresh air till smell is gone. If symptoms persist, inhale steam from shower. Caller told to callback with any further questions or concerns. Callback was declined.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

General health: Caller stated she was suffering from depression and not feeling well and has a bug phobia which is why she left it out for so long. No medications and no known allergies.