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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2021-2447

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.


4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.


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.


PMRA Registration No. 32352      PMRA Submission No.       EPA Registration No.


  • Active Ingredient(s)
      • Guarantee/concentration .6 %

7. b) Type of formulation.

Other (specify)

Repellent coils

Application Information

8. Product was applied?


9. Application Rate.


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

Site: Res. - Out Home / Rés - à l'

Préciser le type: Outside apartment building

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

Neighbours in apartment building burn mosquito coils on balconies on floors below (including ground level), leaving the coils unattended at night. Smoke from coils rises and enters apartments above via air intake vents, open windows and poor seal around windows in general (drafty even when closed). Product label allows burning on proches, but does not consider impact of smoke entering nearby by indoor areas when used at residences within close proximity to each other (apartments, row housing, etc.). Label needs additional restrictions for use in these areas.

To be determined by Registrant

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


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.


  • Respiratory System
    • Symptom - Burning lungs
    • Symptom - Sneezing
  • Eye
    • Symptom - Itchy eye
    • Symptom - Watery eye
  • Respiratory System
    • Symptom - Asthma
    • Specify - Getting worse from exposure to the smoke
    • Symptom - Bronchitis
    • Specify - Getting worse from exposure to the smoke
  • Cardiovascular System
    • Symptom - Palpitations
    • Specify - Pre-existing medical condition

4. How long did the symptoms last?

Unknown / Inconnu

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


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


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)

10. Route(s) of exposure.


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.)

Smoke from the coils causes burning in lungs and allergic reaction: sneezing and itchy, watery eyes. Severe asthma and bronchitis getting worse from exposure to the smoke coming in through windows from balconies below. The smoke triggers heart palpitations due to medial condition.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.