Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2020-4697

2. Registrant Information.

Registrant Reference Number: 6273114

Registrant Name (Full Legal Name no abbreviations): Premier Tech Brighton Ltd

Address: 10 Loyalist Dr

City: Brighton

Prov / State: ON

Country: Canada

Postal Code: K0K 1H0

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

07-OCT-20

5. Location of incident.

Country: CANADA

Prov / State: PRINCE EDWARD ISLAND

6. Date incident was first observed.

25-AUG-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. 13074      PMRA Submission No.       EPA Registration No.

Product Name: Pro Ant and Roach Pyrodust

• Active Ingredient(s)
  • PIPERONYL BUTOXIDE
  • PYRETHRINS

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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 reports that they have a bug problem and an agency came and put an insecticide all over house. This is the 2nd application. Applied one time in August. And then another one last Tuesday.

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

• Gastrointestinal System
  • Symptom - Nausea

• Skin
  • Symptom - Erythema

• Eye
  • Symptom - Blurred vision

• Gastrointestinal System
  • Symptom - Stomach cramps
  • Symptom - Stomach pain

• Nervous and Muscular Systems
  • Symptom - Dizziness

• Gastrointestinal System
  • Symptom - Mouth Irritation

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Unknown

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.)

Caller reports that they have a bug problem and an agency came and put an insecticide all over house. This is the 2nd application. Applied one time in August. And then another one last Tuesday. She had a reaction the first time as well that was prolonged. Product applied Tuesday last week. And stayed away from home. Doctor had said with her sensitivity to stay away longer. She went home Sunday to clean up an ended up the the ER. In the ER this time she got EPI and Benadryl. She is to be on Benadryl for the next few days to avoid her Epi. She is on Prednisone. Her face off and on symptomatic - if coming due for her next meds it is flushed and warm and tingling face. Today not terrible. Addendum Late entry clarification: In call, (name)/patient reports two separate exposures. 1. Most recent exposure; applied one time in August. Date of application Tuesday August 18th. Returned to house on Sunday the 23rd of August. Experienced a reaction and went to emergency department and was treated and released. 2. Prior exposure; on or around November 25, 2019 product applied, exposure and hospitalization. Prolonged recovery period. Caller reports that the emergency room sent a picture of the product to her phone and the product is "Domestic" and the Reg. Number is 13074 PCP ACT (This PCP code matches the Pro Ant and Roach Pyrodust PCP code.) A: Clarification: Adverse reaction to Pyrethrin product PCP Reg Number 13074. Patient medically evaluated, treated, and released.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

The information contained in this report is based on self-reported statements provided to the registrant during telephone interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether th reported clinical effects are causally related to exposure to the product identified.