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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-2254

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.

Human

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

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.

Product Name: Foray Biological Insecticide (Unspecified Formulation)

• Active Ingredient(s)
  • BACILLUS THURINGIENSIS SUBSPECIES KURSTAKI (ALL STRAINS)

7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Pub. Area - Outdoor/Zone publique - ext

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

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: Unknown

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

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Rash
  • Symptom - Itchy skin
  • Symptom - Burning skin
  • Symptom - Other
  • Specify - Scaly skin
  • Symptom - Irritated skin
  • Symptom - Dermatitis

• General
  • Symptom - Pain

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

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)

Drift from the application site

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?

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 followed the guidelines for the days that spraying occurred and remained indoors, with windows closed until well over an hour after spraying stopped. I do not know when exposure occurred or how it occurred. On the first day of spraying, the skin on my face began to itch and burn - red bumps and scaly skin rash spread on my face, neck and chest. Irritation is ongoing and increased in severity after each subsequent day of spraying over the past two weeks. The irritation continues to spread and is extremely itchy. I've been to the doctor - he describes it as contact dermatitis and has prescribed an ointment. The itching and pain continues and has spread to my chest. I have never experienced any type of skin reactions like this before. I've enclosed a couple of pictures showing the rash on my face.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.