Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-2340

2. Registrant Information.

Registrant Reference Number: 3526374

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.

20-FEB-23

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

18-FEB-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.

Other

2. Demographic information of data subject

Sex: Male

Age: >6 <=12 yrs / > 6 < = 12 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Diarrhea
  • Symptom - Stomach cramps
  • Symptom - Nausea
  • Symptom - Vomiting
  • Symptom - Stomach pain

• Skin
  • Symptom - Other
  • Specify - Bug bite

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)

What was the activity? Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding the activity

Other

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.

Skin

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>1 wk <=1 mo / > 1 sem < = 1 mois

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.)

2/20/2023 Consumer reached out about her [age] year old son experiencing nausea, diarrhea, and stomach cramping after the Temprid SC Insecticide was used in their home. The product was applied by a pest control company inside and around the perimeter of her home on February 9, 2023. The family remained out of the home for 9 hours though they were only instructed to vacate for 6 hours. On February 18, 2023 her son vomited randomly without showing any other signs or symptoms of illness. No one else in the home has been sick. This morning he informed her that his stomach hurt. He has had diarrhea and vomited once approximately 90 minutes ago. Consumer gave him water to drink and plans to give him Gravol and Benadryl if signs and symptoms continue. She placed a call to his pediatrician to discuss his signs and symptoms and is awaiting a call back. The pest control company is expected back tomorrow to repeat the application so she wants to make sure the product is not the cause of her son's signs and symptoms. Her concern is that her son is often playing on the floor with his Legos so she wonders if the product got on his toys. She reports that he was bitten by a bug yesterday and she was unsure if his signs and symptoms were due to the bug bite. Consumer is attempting to rule out all potential causes since no one else in the home is sick.

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.