Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2022-3578

2. Registrant Information.

Registrant Reference Number: 6480366

Registrant Name (Full Legal Name no abbreviations): Premier Tech Limited

Address: 1, avenue Premier

City: Riviere-du-Loup

Prov / State: QC

Country: Canada

Postal Code: G5R 6C1

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

15-NOV-21

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

15-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)

---

PMRA Registration No. 21890      PMRA Submission No.       EPA Registration No.

Product Name: Green Earth Garden Sulphur (Fungicide)

• Active Ingredient(s)
  • SULPHUR

---

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. - Out Home / Rés - à l'ext.maison

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

Caller reported that during application some of the product misted onto his face and hands. He washed it off immediately. Symptoms reported started 2 days later.

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: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Headache

• Respiratory System
  • Symptom - Nose bleed
  • Symptom - Sneezing
  • Symptom - Sinus pain
  • Symptom - Runny nose

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.

Skin

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>8 hrs <=24 hrs / > 8 h < = 24 h

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.)

Caller advised that the exposure occurred two days earlier. Product was rinsed off skin for 10 minutes. The symptoms reported began a day later. Specialist at poison control centre assessed that the symptoms were probably not related to the exposure, due to time between exposure and symptoms.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.