Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2020-4860

2. Registrant Information.

Registrant Reference Number: 2020-24

Registrant Name (Full Legal Name no abbreviations): BASF Canada Inc.

Address: 100 Milverton Drive, 5th Floor

City: Mississauga

Prov / State: Ontario

Country: Canada

Postal Code: L5R 4H1

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

Human

4. Date registrant was first informed of the incident.

19-OCT-19

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

Unknown

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. 27864      PMRA Submission No.       EPA Registration No.

Product Name: Prescription Treatment Brand AVERT Granular Carpenter Ant Bait

• Active Ingredient(s)
  • ABAMECTIN

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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 she lived in an apartment for two years where the product was used (she has recently moved). Caller states she believes she was contaminated by the product.

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 - Tingling skin

• General
  • Symptom - Other
  • Specify - Black lines in nails
  • Symptom - Other
  • Specify - Blood feels like molasses
  • Symptom - Other
  • Specify - Brain hurts
  • Symptom - Other
  • Specify - Chin bouncing
  • Symptom - Other
  • Specify - Eyelids twitching
  • Symptom - Other
  • Specify - Nail quickly shortening
  • Symptom - Other
  • Specify - Nails feel like they will explode
  • Symptom - Other
  • Specify - Nails flattened
  • Symptom - Other
  • Specify - Nails receding and peeling

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)

Contact with treated area

What was the activity? Caller reports she lived in an apartment for two years where the product was used.

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 states she has seen her MD multiple times. Caller described symptoms including: nails feel like they will explode,nails flattening, black lines in nails, nail quick shortening, nails receding and peeling, pin and needles everywhere, chin bouncing, brain hurts, and blood feeling like molasses. She has been tested for zinc,arsenic, and mercury poisoning. Her MD told her she has psychosis and has referred her to a mental health specialist. Caller refuses to take medications she is prescribed for depression and anxiety. She refuses to see a mental health specialist and states she has been contaminated. Caller states she does not know if it was this product or something else.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.