Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2022-1761

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.

Packaging Failure

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

21-NOV-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)

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PMRA Registration No. 21465      PMRA Submission No.       EPA Registration No.

Product Name: PESTCHASER ULTRASONIC RODENT REPELLER

• Active Ingredient(s)
  • DEVICE, NO GUARANTEE REQUIRED

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

Product Name:

• Active Ingredient(s)
  • DEVICE, NO GUARANTEE REQUIRED

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7. b) Type of formulation.

Other (specify)

DEVICE

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).

Victor Pest Chaser and Rodent Repellent with Night Light (110 AC 50/60 Hz o.3W Woodstream www.victorpest.com) plugged into [Brand] 12 outlet protected and guarded power bar.

To be determined by Registrant

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

Unknown

Subform VI: Packaging Failure

1. What is the type of packaging that failed?

Other / Autre

specify DEVICE (ELECTRICAL)

2. Did packaging failure occur during?

Use of Product

3. Did packaging failure result in?

potential injury

4. Describe how the packaging failed and the surrounding circumstances, including a description of the potential injury or exposure.

I heard strange popping sounds, and the smell of awful smoke, my bedroom fire alarm went off and I ran up to my bedroom and saw the fire and heavy black stinky smoke. Victor Pest Chaser and Rodent Repellent with Night Light (110 AC 50/60 Hz o.3W Woodstream www.victorpest.com) was plugged into [Brand] 12 outlet protected and guarded power bar and caught fire. Flames smothered to stop fire. No injury reported.

For Registrant use only

5. Provide supplemental information here.