Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-7040

2. Registrant Information.

Registrant Reference Number: 6102188

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.

14-AUG-19

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

13-AUG-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. 30158      PMRA Submission No.       EPA Registration No.

Product Name: Wilson One Shot Bed Bug Killer

• Active Ingredient(s)
  • D-PHENOTHRIN
  • TETRAMETHRIN

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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 used the product on the bed and mattress. She wore a mask. She left the room and closed the door. She went in after to open up the window to ventilate. She could smell the fumes when she walked by the closed door. Smell did disappear and she couldn't smell it anymore.

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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Dizziness

• Gastrointestinal System
  • Symptom - Dry mouth

• General
  • Symptom - Other
  • Specify - coated tongue

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?

No

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.

>3 days <=1 wk / >3 jours <=1 sem

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.)

Caller used the product on the bed and mattress, but she was wearing a mask. She closed the door. She went in after to open up the window to ventilate. She could smell the fumes when she walked by the closed door. Smell did disappear and she couldn't smell it anymore. She slept on the couch, but she has a vent that goes from her room to where the couch is located. She used the product Friday (8/9/19) and noticed her mouth was dry and her tongue had a coating on it August 13 and 14. This morning she was also feeling light headed, but now resolved.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.