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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-0183

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.


4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

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.       PMRA Submission No.       EPA Registration No.


  • 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: 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).

Four years ago I was exposed to a fogging treatment in our student housing which was a traumatic event that has been eating away at my thoughts. I was in a student home studying at [University] when a bug spray company performed a treatment on the lower floor while I was sleeping on the higher floor. The rooming house, which was illegal was separated into two sections: 1. The bottom half where the Bed Beg treatments took place and 2. The top half where I was living. The smell was of paint and chemicals and I quickly opened the window when I would wake up. I didn't know what was going on and what the smell was until I was notified by the landlord of the treatment after the fact. In the email they mentioned that they sprayed Permethrin, a beg bug neurotoxin multiple times in the house. They repeated this treatment 3 times and I was sleeping each of these times. They made no attempt to notify the living residents on the top floor. I have not signed anything notifying that I was aware of these applications.

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: Unknown

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

3. List all symptoms, using the selections below.


  • General
    • Symptom - Lightheadedness
  • Nervous and Muscular Systems
    • Symptom - Headache
  • General
    • Symptom - Other
    • Specify - Fear of brain damage
    • Symptom - Other
    • Specify - Fear of negative health issues

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)


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.)

I was experiencing light headedness and headaches after the exposure. The negative effects were both physical and psychological. This event caused fear of brain damage and other negative health issues. However, the concern now is that these negative thoughts keep interfering with my life.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.