Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2023-2451
2. Registrant Information.
Registrant Reference Number: 6648635
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.
18-FEB-23
5. Location of incident.
Country: CANADA
Prov / State: SASKATCHEWAN
6. Date incident was first observed.
17-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)
PMRA Registration No. 29485
PMRA Submission No.
EPA Registration No.
Product Name: Schultz Houseplants and Indoor Garden Insect Spray
- Active Ingredient(s)
- PIPERONYL BUTOXIDE
- PYRETHRINS
7. b) Type of formulation.
Application Information
8. Product was applied?
No
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
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: Male
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Erythema
- Symptom - Irritated skin
- Symptom - Other
- Specify - Lump on finger
- Symptom - Pain
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
Occupational
8. How did exposure occur? (Select all that apply)
Pesticide Spill
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?
<=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.)
Symptoms were minor but given caller's previous existing medical conditions and the lump that formed after exposure, it was recommended he get medical attention. Followup calls and messages were made to the caller.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.