Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2019-7041
2. Registrant Information.
Registrant Reference Number: 6102533
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.
15-AUG-19
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
15-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)
PMRA Registration No. 26904
PMRA Submission No.
EPA Registration No.
Product Name: Wilson Ready To Use Home Pest Control
7. b) Type of formulation.
Application Information
8. Product was applied?
No
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
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
- Gastrointestinal System
- Symptom - Irritated throat
4. How long did the symptoms last?
>30 min <=2 hrs / >30 min <=2 h
5. Was medical treatment provided? Provide details in question 13.
No
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)
Pesticide Spill
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
10. Route(s) of exposure.
Respiratory
11. What was the length of exposure?
<=15 min / <=15 min
12. Time between exposure and onset of symptoms.
<=30 min / <=30 min
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 said the producct leaked onto her basement carpet. Said the odor was very strong and smelled very toxic. Said she does feel like she has a throat irritation. Currently outside and is ventilating basement.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
Followed up with caller about one hour after initial discussion. Stated she was feeling normal after performing recommended actions (shower and ventilate). Throat irritation was resolved