Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2020-1251

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: BRITISH COLUMBIA

6. Date incident was first observed.

07-MAR-20

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: IQ Pure Air 3000

• Active Ingredient(s)
  • OZONE

---

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

Product Name: IQ Pure Air 50

• Active Ingredient(s)
  • DEVICE, NO GUARANTEE REQUIRED
  • OZONE

---

7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

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: We purchased a IQ Pure Air 3000 and two smaller IQ Pure Air 50's from (name) at a Home Show in (city), BC. They said these would improve the air quality in our home and were good for allergy and asthma sufferers and this is why we bought them. Total cost: $985. We used them in our home from Jan 20 to Mar 28, 2020 (69 days). The larger IQ 3000 unit was placed on a shelf above my computer which is in a large open area of about 900-1000sqft, and was normally set to 500. The 2 smaller devices were used in each of our kids' rooms; one in the basement and one on the main floor. The rep said we could set it to the sqft. of the area being used including rooms with open doors.

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

• Skin
  • Symptom - Lesion
  • Specify - sores inside nose and on skin
  • Symptom - Dry skin

• Eye
  • Symptom - Dry eye

• Gastrointestinal System
  • Symptom - Dry throat

• General
  • Symptom - Malaise

• Skin
  • Symptom - Cracked skin

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)

Other

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

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

>1 mo <= 6 mos / > 1 mois < = 6 mois

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: Over the next 2 months, I gradually experienced painful sores that would come and go; especially on my hands, I got sores inside my nose, and on other parts of my skin. I sat directly below the unit for 2 weeks a month while I worked on my computer, which explains why my symptoms would come and go. On March 17 my son had a severe asthma attack. After his episode he increased the output on the device in his room AND the one above my computer to 1000 (still within the sqft), which is why I presume my symptoms started getting worse. By Mar 28 my symptoms had got much worse; I had dry eyes, a dry throat, my hands became extremely dry and cracked with open sores and lotions didn't help, overall I felt poorly and realized something was very wrong and not normal. I decided to investigate ozone generating devices online and found out the dangers. I turned them off immediately and my symptoms are now starting to improve.

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: Male

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Asthma
  • Specify - asthma attack

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)

Other

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

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

>1 mo <= 6 mos / > 1 mois < = 6 mois

12. Time between exposure and onset of symptoms.

>1 mo <=2 mos / > 1 mois < = 2 mois

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: On March 17 my son had a severe asthma attack. After his episode he increased the output on the device in his room AND the one above my computer to 1000 (still within the sqft), which is why I presume my symptoms started getting worse. He turned them up to improve his asthma symptoms which seemed to be getting worse.

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: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Dry skin
  • Symptom - Cracked skin

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)

Other

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

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

>1 mo <= 6 mos / > 1 mois < = 6 mois

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: My daughter unplugged hers after about a month because of a high pitched ringing noise, but also experienced a dry and cracked nose during the time it was on.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.