Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-2339

2. Registrant Information.

Registrant Reference Number: 3496419

Registrant Name (Full Legal Name no abbreviations): 2022 Environmental Science CA Inc

Address: 137 Glasgow Street, Suite 210

City: Kitchener

Prov / State: ON

Country: Canada

Postal Code: N2G 4X8

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

Human

4. Date registrant was first informed of the incident.

16-JAN-23

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

16-JAN-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. 32524      PMRA Submission No.       EPA Registration No.

Product Name: TEMPRID SC INSECTICIDE

• Active Ingredient(s)
  • BETA-CYFLUTHRIN
  • IMIDACLOPRID

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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).

Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding application.

To be determined by Registrant

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

Yes

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: Female

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

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Irritated throat

• Respiratory System
  • Symptom - Shortness of breath

• Gastrointestinal System
  • Symptom - Dry throat

• Respiratory System
  • Symptom - Other
  • Specify - Felt like it was difficult to breathe

4. How long did the symptoms last?

Unknown / Inconnu

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)

Contact with treated area

Amount of time between application and contact 6

Hour(s) / Heure(s)

What was the activity? Reentry into a treated apartment.

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

None

10. Route(s) of exposure.

Respiratory

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.)

1/16/2023 Caller reports that a pesticide company treated her apartment with this product today at 1:50pm. She returned home at 7:37pm with 20 minutes left before she was supposed to reenter the treated area; however, she needed to use the restroom so she went inside. She immediately experienced some dry irritation in her throat, and she felt like it was difficult to breathe. She went outside during call and her symptoms began to improve.

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(s). 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 a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews.