Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2022-2165

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: QUEBEC

6. Date incident was first observed.

07-JUN-22

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. 29759      PMRA Submission No.       EPA Registration No.

Product Name: DOKTOR DOOM "GO GREEN" PREMIUM QUALITY PYRETHRIN INSECTICIDE POWDER FO

• Active Ingredient(s)
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration 1 %
  • PYRETHRINS
    • Guarantee/concentration .2 %

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7. b) Type of formulation.

Wettable or soluble powder

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: TERRE DES PLANTES D'INTERIEUR

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

Application de la poudre sur la terre de mes plantes d'interieur entre vendredi et lundi.

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

• Nervous and Muscular Systems
  • Symptom - Difficulty talking
  • Specify - Difficulte a parler et articuler
  • Symptom - Other
  • Specify - Machoire tendue

• Gastrointestinal System
  • Symptom - Mouth Irritation
  • Specify - Langue irritee

• Respiratory System
  • Symptom - Coughing

• General
  • Symptom - Pain
  • Specify - Douleur a la langue

• Gastrointestinal System
  • Symptom - Other
  • Specify - Sensation d'inflammation a la langue

• Respiratory System
  • Symptom - Irritated throat

• General
  • Symptom - Discomfort

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)

Application

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.

Oral

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

Difficulte a parler et articuler, machoire tendue comme lorsqu'on a trop froid pour parler, langue irritee, toux, douleur a la langue, sensation d'inflammation a la langue lorsque j'appuie avec mes dents sur ma langue, irritation a la gorge. Les symptomes de la difficulte a articuler pour parler est tout de suite apparue mais sans faire un lien. Jusqu'au lundi quand j'ai parle avec une amie infirmiere qui m'a demande si j'avais fait quelque chose de nouveau. C'est le seul produit avec lequel j'ai ete nouvellement en contact. Lundi j'ai eu les autres symptomes decrit en plus de la difficulte a parler. Entre vendredi et lundi je n'avais pas sentie d'inconfort immediat en utilisant le produit. Mais lundi quand j'en ai remis dans mes plantes, c'etait hora de tout doute, la toux et la gorge ont ete affectes quasi instantanee et j'ai sentie vraiment un inconfort rapidement! C'etait desagreable et tres irritant. J'espere que les symptomes vont vites disparaitre. Je vais prendre du benadryl et j'ai rendez vous avec mon medecin vendredi.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.