Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-1584

2. Registrant Information.

Registrant Reference Number: 6655648

Registrant Name (Full Legal Name no abbreviations): Premier Tech Brighton Ltd

Address: 10 Loyalist Dr

City: Brighton

Prov / State: Ontario

Country: Canada

Postal Code: K0K1H0

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

Human

4. Date registrant was first informed of the incident.

11-APR-23

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

10-MAR-23

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. 28290      PMRA Submission No.       EPA Registration No.

Product Name: Pro Professional Bug-X Ready-To-Use Insecticide

• Active Ingredient(s)
  • PERMETHRIN
  • TETRAMETHRIN

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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).

Caller stated he sprayed Pro Bug-X RTU Insecticide inside of his home.

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: Female

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Other
  • Specify - Itching

• Nervous and Muscular Systems
  • Symptom - Headache

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

Unknown

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

Other

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.

Respiratory

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.)

Exposure to product fumes/vapour in poorly ventilated area. Caller stated that he sprayed Pro Bug-X RTU Insecticide inside of his home. Waited 13 hours and then went back into the house. When his wife entered back into the house she started to feel itchy and get a headache. He then opened all the windows in the house for fresh air. The itching had stopped today, but his wife still had a mild headache. Response: Keep Hydrated (may sip on cool/warm fluids). Move to fresh air environment. Ventilate indoor areas with fresh air till smell is gone. If symptoms persist, inhale steam from shower. Therapy Type: Dilute/irrigae/was was recommented.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

The information contained in this report is based on self-reported statements provided to the registrant during telephone interview. These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for as determination of whether the reported clinical effects are causally related to exposure to the product identified.