Health Canada
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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2021-2047
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: ONTARIO
6. Date incident was first observed.
06-MAY-21Product 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: Dragnet FT Emulsifable Insecticide
- Active Ingredient(s)
- PERMETHRIN
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. - In Home / Rés. - à l'int. maison
Préciser le type: Apartment Building
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Resident of the apartment reported fumes in their apartment from being sprayed with Dragnet. Apartment was sprayed on 2 occaisions spread apart by 2 weeks.The resident re entered 4 to 5 hours after the application had occurred.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: Male
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Cardiovascular System
- Symptom - Chest tightness
- Specify - Involuntary compressive stimulation of chest area
- Gastrointestinal System
- Symptom - Stomach pain
- General
- Symptom - Taste altered
- Specify - Bad taste in mouth
- Respiratory System
- Symptom - Coughing
- Symptom - Irritated throat
- Symptom - Runny nose
- Symptom - Difficulty Breathing
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
No
6. a) Was the person hospitalized?
No
6. b) For how long?
7. Exposure scenario
Unknown
8. How did exposure occur? (Select all that apply)
Contact with treated area
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
10. Route(s) of exposure.
Respiratory
11. What was the length of exposure?
>1 wk <=1 mo / > 1 sem < = 1 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 individual returned 4-5 hours after the apartment was sprayed with Dragnet and started to experience symptoms. The individual reported breathing difficulties, coughing, throat irritation, and difficulty going to sleep due to the breathing issue. While lying in bed they found involuntary compressive stimulation of their chest area, feeling that the lungs were somehow affected and causing some form of action similar to a decompression effect. The symptoms of having the tendency to cough and lung irritation have been ongoing since the icident.
