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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-2719

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.


4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

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. 24175      PMRA Submission No.       EPA Registration No.


  • Active Ingredient(s)

7. b) Type of formulation.


Application Information

8. Product was applied?


9. Application Rate.


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

Site: Unknown / Inconnu

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

For the last three years, our neighbour has had his property sprayed with a pesticide to kill mosquitos. It started Year 2021 to this current Year 2023. The pesticide contractor was also contacted last season and their response: "IT IS SAFE!". We also wrote them an email and received a lengthy reply of how "SAFE" it is.

To be determined by Registrant

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


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: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.


  • General
    • Symptom - Other
    • Specify - Allergic reaction
  • Nervous and Muscular Systems
    • Symptom - Confusion
    • Specify - Cant think
  • General
    • Symptom - Weakness
    • Symptom - Insomnia
  • Nervous and Muscular Systems
    • Symptom - Headache
  • General
    • Symptom - Pain
  • Cardiovascular System
    • Symptom - Hypertension
  • Gastrointestinal System
    • Symptom - Diarrhea
  • Respiratory System
    • Symptom - Difficulty Breathing
  • Nervous and Muscular Systems
    • Symptom - Difficulty walking
    • Specify - Using a walker
    • Symptom - Confusion
    • Specify - Mind blur

4. How long did the symptoms last?

Unknown / Inconnu

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


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


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)


10. Route(s) of exposure.


11. What was the length of exposure?

Unknown / Inconnu

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.)

The emulsion of the pesticide spray drifted it's poison onto our property and environs and in our home as well thru wide open patio doors. Year 2021 After 2 rounds of pesticide sprays the allergic reaction kicked in. Overnight using a walker after the 2nd round of spray! Can't think! Can no longer function. So weak daily I almost pass out. Horrific indescribable nights of insomnia, horrific headaches, pains in legs and back. I am howling in pain. Trip to emergency hospital as emerge doctor conducted every test possible confirming the pesticide allergy. He'd seen it before. Prior to pesticides I'd been full of health often walking with my husband the nearby trail or riding bikes together in long distances. Daily dose of Activated Charcoal alleviated some of the poison. Still it took a toll on my health as I began to have grievous issues with high blood pressure -no issues prior. My husband and I escaped our property for a couple of weeks! Would you know insomnia headaches diarrhea disappeared (tho the pesticides had left my body horribly weakened!) Year 2022 May rolled around and neighbour ignored our plea and sprayed again twice leaving me so debilitated my husband has to take care of me. Headaches insomnia howling pains thru the night all over again tho the pesticides had never left my body neither our home or outdoors. My mind a dangerous blur. No breath left. Activated charcoal flushes enough poison to survive. We now close all doors and windows. I could no longer do yard work in our gardens having to abandon our organic garden. My husband cannot reenter the house without a shower and changing his clothes as the pesticides in the air are persistent all year round clinging to his skin causing me instant allergic reactions. Even the furniture is affected inside the house. We were given no choice but to abandon our waterfront home. For 5 months we hide in a little unheated trailer till end of December in [Company] parking lots mostly but now able to sleep 10 hours nightly. This year 2023 this neighbour has once again proceeded with the product application with the 1st application applied on the 24th of May. I cannot go out side our home any more or open our windows for fresh air! Or patio doors. To go in and out of the house I must put on a special mask that allows me a short time outside. In January 2023 we have had to invest in 2 expensive AIR PURIFIERS just to be able to live in our home and that barely! In February of same year we had to buy a 3rd one [Product] to trap the persistent pesticides! Some still persist. Daily diarrhea, insomnia etc has ensued.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.