Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2020-5906

2. Registrant Information.

Registrant Reference Number: PI01

Registrant Name (Full Legal Name no abbreviations): HEIDI KUUS

Address: UNIT 5 AND 6, 450 TAPSCOTT ROAD

City: TORONTO

Prov / State: ONTARIO

Country: CANADA

Postal Code: M1B 1Y4

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

Human

4. Date registrant was first informed of the incident.

08-NOV-20

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

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. 31463      PMRA Submission No.       EPA Registration No.

Product Name: MOSQUITO SHIELD PIACTIVE INSECT REPELLENT

• Active Ingredient(s)
  • ICARIDIN

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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: Personal use / Usage personnel

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Product was sprayed on to the skin and eyes

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

No

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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Edema

• Skin
  • Symptom - Irritated 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)

Application

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

None

10. Route(s) of exposure.

Skin

Eye

11. What was the length of exposure?

<=15 min / <=15 min

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.)

Person's lawyer contacted our company that he suffered eye injury and skin rashes due to the product getting into his eyes because of defective spray. He sent the pictures of the eye injury and skin lesions.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.