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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2022-4970

2. Registrant Information.

Registrant Reference Number: KIH

Registrant Name (Full Legal Name no abbreviations): KIK Holdco Company Inc.

Address: 33 MacIntosh Blvd.

City: Concord

Prov / State: ON

Country: Canada

Postal Code: L4K 4L5

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


4. Date registrant was first informed of the incident.


5. Location of incident.

Country: CANADA

Prov / State: UNKNOWN

6. Date incident was first observed.


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.


PMRA Registration No. 26666      PMRA Submission No.       EPA Registration No.

Product Name: Spa Synergy Tabs

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


10. Site pesticide was applied to (select all that apply).

Site: Other / Autre

Préciser le type: Spa

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

Along with the Spa Synergy tabs, customer also used Spa Synergy Initiator and Spa Synergy Clear which fall under CCCR guidelines to balance the brand new spa.

To be determined by Registrant

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


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: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • Skin
    • Symptom - Rash
    • Specify - Pseudomonas

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


8. How did exposure occur? (Select all that apply)

Contact with treated area

What was the activity? Customer used brand new spa which was treated with Spa Synergy Tabs

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)


10. Route(s) of exposure.


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.)

Customer used brand new spa which was treated with Spa Synergy Tabs (PCP 26666), Spa Synergy Initiator and Spa Synergy Clear. And filed a complaint of rash with the dealer who is located in [Province]. Dealer followed up with customer and found out the customer went to see doctor and doctor diagnosed the rash as psuedomonas. The water was rebalanced with the same products again and the rash cleared up.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.

Water was rebalanced with same products, rash was cleared and customer didn't file another episode of the adverse event.