Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2021-6664
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
Domestic Animal
4. Date registrant was first informed of the incident.
5. Location of incident.
Country: CANADA
Prov / State: QUEBEC
6. Date incident was first observed.
15-DEC-21
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)
PMRA Registration No. 32524
PMRA Submission No.
EPA Registration No.
Product Name: TEMPRID SC
- Active Ingredient(s)
- BETA-CYFLUTHRIN
- IMIDACLOPRID
PMRA Registration No. 15255
PMRA Submission No.
EPA Registration No.
Product Name: DRIONE INSECTICIDE DUST
- Active Ingredient(s)
- PIPERONYL BUTOXIDE
- SILICA AEROGEL
PMRA Registration No. 24175
PMRA Submission No.
EPA Registration No.
Product Name: DRAGNET FT EMULSIFIABLE CONCENTRATE INSECTICIDE
PMRA Registration No. 30092
PMRA Submission No.
EPA Registration No.
Product Name: KNOCK DOWN FARM, LIVESTOCK, FOOD PROCESSING PLANTS & INSTITUTIONAL INS
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).
I do not have bugs, never caught any in traps over 2 year course of hassle. Forced to Pack up twice for full extermination anyhow. They keep spraying my hallway and in cracks that lead into my living room, as well as under a large gap under my doorway, gassing us in without notice.
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
- General
- Symptom - Chemical taste in mouth
- Nervous and Muscular Systems
- Symptom - Headache
- Symptom - Dizziness
- Respiratory System
- Symptom - Irritated throat
- Symptom - Other
- Specify - Irritated sinuses
- Blood
- Symptom - Other
- Specify - Inflammation markers
- General
- Symptom - Pain
- Symptom - Swelling
- Specify - Limbs
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)
Contact with treated area
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.
Respiratory
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.)
Toxic poisonous smell permeating for days despite windows being open and fans running. Foul taste coating mouth when breathing, toxic poisonous smell permeating for days despite windows being open and fans running,skin irritations, headaches, slight dizzy spells, irritated throat and sinuses when in the apartment. . Inflammation markers in blood, with sudden unknown causes of chronic pain and limb swelling that led to hospital visits and bloodwork with unclear results. We keep walking through common areas without ventilation through poison on a weekly basis, children included. I have allergies and asked to be notified and vacate premises during, and he said he had no obligation to do so. Their products clearly don't work as there is still a cocroach problem. There needs to be a healthier approach, as all neighbours are complaining about sore throats, coughs, terrible smell, headaches and skin problems.
To be determined by Registrant
14. Severity classification.
15. Provide supplemental information here.
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
Unknown
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- General
- Symptom - Polydipsia
- Symptom - Hiding
- General
- Symptom - Licking
- Symptom - Hair loss
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Unknown/Inconnu
16. How was the animal exposed?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Cats drinking excessively, hiding under beds and closets and vomiting, excessive licking and shedding (they are well groomed and taken care of and this is unusual and tied to timing).
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Not Applicable
19. Provide supplemental information here