Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-1102

2. Registrant Information.

Registrant Reference Number: 6604021

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.

14-OCT-22

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

14-OCT-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. 26923      PMRA Submission No.       EPA Registration No.

Product Name: Wilson ant Killer Dust

• Active Ingredient(s)
  • CARBARYL

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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. - 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).

The caller indicated that he had the dust on the floor. No further information was provided about application.

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.

Other

2. Demographic information of data subject

Sex: Male

Age: >1 <=6 yrs / > 1 < = 6 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Vomiting

4. How long did the symptoms last?

<=30 min / <=30 min

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

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

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.

Unknown

11. What was the length of exposure?

<=15 min / <=15 min

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.)

Caller indicated that child's drinking cup fell to the floor and might have come in contact with the dust product. Child vomited immediately after drinking milk from cup. Child, who takes asthma medication daily was taken to Emergency Department. No further symptoms after initial vomiting. Family left Emergency Department without seeing a health care professional.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

A followup call was made to determine outcome. Father indicated that the child was fine and had been eating and drinking normally.