Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2020-1541

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

Domestic Animal

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

22-MAY-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)

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

Product Name: DRAGNET

• Active Ingredient(s)
  • PERMETHRIN

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7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Res. - Out Home / Rés - à l'ext.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: On May 22, 2020, my neighbors had a company (name) fog/spray their lawn for mosquitoes. I didn't know this was happening and I was outside in the backyard with my dog. I heard a noise like a lawn mower between the houses and the technician approached the backyard I smelled something funny and noticed the fog jetting out of this machine towards my property where my dog was. We have a chain link fence, so the chemical fog was jetting out to my property and spraying my dog. The technician knew my dog was on the other side and saw him as the foliage is no more then a foot high. Plus, I went there to try to get my dog away from the fence and the technician didn't stop. My dog was interested and thought the guy was playing. My dog thought it was exciting as he was getting a mouth full of chemical fog and sneezing. When the technician went to leave, I tried to get his attention to ask him about the chemical. He stopped, I asked him if it is safe what he was using. He said it's no different then the flea and tick chemical you put on your dog and walked away. I attempted to call (name) as I wanted to know what my dog and I were exposed to. I ran into my neighbors the next day and told them the situation. I asked them about the chemical used. She said that it was harmless and that the company told her it's organic. I noticed the sign on their lawn showing a picture "Pesticide" Do not walk. Called (name) again on May 29, 2020 and reported the incident. The company told me all their products are environmentally friendly and gave me the name of the chemical, Dragnet. I asked if it was safe while it's being applied for dogs and humans. She said it was. I beg to differ.

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

• Respiratory System
  • Symptom - Sore throat

• General
  • Symptom - Lethargy
  • Symptom - Malaise

• Respiratory System
  • Symptom - Respiratory pain
  • Specify - sore lungs

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)

Drift from the application site

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.

<=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.)

The following was reported: I instantly got a sore throat and started not to feel well. I called the company who applied the chemical, but started to really feel tired and my lungs hurt and they were not answering. I went to rest as I really felt sick. I felt a bit better that night, not 100% for the past few days. Lungs don't hurt as much.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

unknown

4. Number of animals affected

5. Sex

Male

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Respiratory

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

<=30 min / <=30 min

11. List all symptoms

System

• Respiratory System
  • Symptom - Sneezing

• General
  • Symptom - Lethargy

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.

Unknown

14. a) Was the animal hospitalized?

Unknown

14. b) How long was the animal hospitalized?

Unknown

15. Outcome of the incident

Unknown/Inconnu

16. How was the animal exposed?

Spray drift / Dérive de pulvérisation

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

The following was reported: My Dog was sneezing when the fog was directed at him through the chain link fence when my neighbours got the application done to kill mosquitoes. My dog has been unusually lackadaisical.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Not Applicable

19. Provide supplemental information here