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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2020-0058

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: ONTARIO

6. Date incident was first observed.

05-SEP-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.       PMRA Submission No.       EPA Registration No.

Product Name: Endrin//Heptachlor Exopide

  • Active Ingredient(s)
    • ENDRIN

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

Product Name: Endossultan

  • Active Ingredient(s)
    • ENDOSULFAN

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

Product Name: Heptachlor Exopide

  • Active Ingredient(s)
    • HEPTACHLOR

7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

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: All areas sprayed walls, floor, ceiling and household items. Items in the kitchen and cupboards. Walls with spray marks and wiped on the walls. Different chemicals have been analyized at Cassen Laboritories 2017 and EMSL 2019 as my health and my Landladys health deteriate. We are x and x years of age. You can see the spray marks on the walls and the carpet in the bedroom were removed due to fumes from them, but the walls, wood floor is marked from chemicals and the ceiling stucco needs to be tested. Additonal testing will take place with EMSL labs for pesticides in the carpets in the Dining Room and Living Room.

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: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

  • Eye
    • Symptom - Burning eye
  • Gastrointestinal System
    • Symptom - Vomiting
  • Respiratory System
    • Symptom - Decreased pulmonary function
  • Skin
    • Symptom - Burns (superficial)
    • Symptom - Irritated skin
  • Nervous and Muscular Systems
    • Symptom - Muscle cramps
    • Symptom - Muscle tremors
    • Symptom - Dizziness
  • Eye
    • Symptom - Other
    • Specify - Vision problems NOS
  • Ear
    • Symptom - Earache
  • General
    • Symptom - Weakness
  • Respiratory System
    • Symptom - Coughing
    • Specify - Severe
  • Blood
    • Symptom - Other
    • Specify - High creatine kinase (CK)
    • Symptom - Anemia
    • Specify - red blood cells dropping
  • Respiratory System
    • Symptom - Other
    • Specify - markers in the lungs
  • Gastrointestinal System
    • Symptom - Weight loss
    • Symptom - Anorexia
  • General
    • Symptom - Adipsia
  • Gastrointestinal System
    • Symptom - Difficulty swallowing
  • Respiratory System
    • Symptom - Difficulty Breathing
  • General
    • Symptom - Hair loss
  • Gastrointestinal System
    • Symptom - Diarrhea

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)

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.

Unknown

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: Burning eyes, vomiting, breathing issues (respirologist involved due to low lung function), skin burns and irritations, cramps, tremors, dizziness, vison problems, ear aches, weakness, severe coughing,blood work showing high CK and red blood cells dropping as well as markers in the lungs. Currently sever weight lose, cannot eat or drink. Something is very wrong as we have trouble swallowing, breathing and no desire to eat or drink it is very difficult. Fisrt found the residents sprayed in 2017/2018/2019 todate with a chemical - powder caused chemical burns lab analyis and photos of burns Servere vomiting and Diarrhea for month and lost 30 plus pounds, hair exstensive hair lost (entrie body and head) from powdered chemical.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Female

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

  • Eye
    • Symptom - Burning eye
  • Gastrointestinal System
    • Symptom - Vomiting
  • Respiratory System
    • Symptom - Decreased pulmonary function
  • Skin
    • Symptom - Burns (superficial)
    • Symptom - Irritated skin
  • Nervous and Muscular Systems
    • Symptom - Muscle cramps
    • Symptom - Muscle tremors
    • Symptom - Dizziness
  • Eye
    • Symptom - Other
    • Specify - Vision problems NOS
  • Ear
    • Symptom - Earache
  • General
    • Symptom - Weakness
  • Respiratory System
    • Symptom - Coughing
    • Specify - Severe
  • Blood
    • Symptom - Anemia
    • Specify - Red blood cells dropping
    • Symptom - Other
    • Specify - High creatine kinase (CK)
  • Respiratory System
    • Symptom - Other
    • Specify - Markers in the lungs
  • Gastrointestinal System
    • Symptom - Weight loss
    • Symptom - Anorexia
  • General
    • Symptom - Adipsia
  • Gastrointestinal System
    • Symptom - Difficulty swallowing
  • Respiratory System
    • Symptom - Difficulty Breathing
  • Gastrointestinal System
    • Symptom - Diarrhea
  • General
    • Symptom - Hair loss

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)

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.

Unknown

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: Burning eyes, vomiting, breathing issues (respirologist involved due to low lung function), skin burns and irritations, cramps, tremors, dizziness, vison problems, ear aches, weakness, severe coughing,blood work showing high CK and red blood cells dropping as well as markers in the lungs. Currently sever weight lose, cannot eat or drink. Something is very wrong as we have trouble swallowing, breathing and no desire to eat or drink it is very difficult. Fisrt found the residents sprayed in 2017/2018/2019 todate with a chemical - powder caused chemical burns lab analyis and photos of burns Servere vomiting and Diarrhea for month and lost 30 plus pounds, hair exstensive hair lost (entrie body and head) from powdered chemical.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.