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Consumer Product Safety

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

  • Active Ingredient(s)
    • PERMETHRIN

PMRA Registration No. 30092      PMRA Submission No.       EPA Registration No.

Product Name: KNOCK DOWN FARM, LIVESTOCK, FOOD PROCESSING PLANTS & INSTITUTIONAL INS

  • Active Ingredient(s)
    • PERMETHRIN

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
  • Skin
    • Symptom - Irritated skin
  • 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
  • Gastrointestinal System
    • Symptom - Vomiting
  • 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