Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-3211

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: ONTARIO

6. Date incident was first observed.

15-JUN-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. 24175      PMRA Submission No.       EPA Registration No.

Product Name: DRAGNET FT EMULSIFIABLE CONCENTRATE INSECTICIDE

• Active Ingredient(s)
  • PERMETHRIN

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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: Res. - Out Home / Rés - à l'ext.maison

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

The neighbours sprayed their property with another application of pesticide. With the prevailing westerly winds in our area, the product obviously drifted onto our property. We alerted the neighbours -it made no difference. Our appeal was rejected rudely. The pesticide dealers were also contacted and our concerns made known. They stated they will continue the applications as long as they are still being paid. And furthermore stated that as we are not their customers they will not receive our complaints of injuries. I requested that at least they give incident report of them and notify any appropriate authorities. They refused.

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: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Insomnia
  • Symptom - Pain
  • Specify - Acute severe pain, insufferable night pains
  • Symptom - Weakness

• Nervous and Muscular Systems
  • Symptom - Headache

• Gastrointestinal System
  • Symptom - Diarrhea

• Nervous and Muscular Systems
  • Symptom - Confusion
  • Specify - Can barely think, jammed thinking
  • Symptom - Other
  • Specify - Limp
  • Symptom - Difficulty concentrating

• General
  • Symptom - Other
  • Specify - Allergic
  • Symptom - Vocalizing
  • Specify - Howling

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

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.

Respiratory

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.)

That night after their 2nd application I suffered insomnia & acute severe pain throughout that night -so crippling my husband had to help me move inch by inch to make it to the washroom. I howled at the least movement of my body. A body still not recovered from the persistence of pesticides spray of the last 3 years. After those pesticides -to which I am extremely allergic - I wake up weakened & limp with a headache & insufferable night pains & running to the toilet.... Diarrhea is so bad since the application that I can write about the consequences to my body. Ability to concentrate has grievously suffered -it has jammed my thinking. I am allergic to pesticide whether they be in food or environment -both have delibitating consequences. Home air & outdoor air quality here is so polluted it is a daily must for me personally to escape to fresh air in children's parks just to survive. My husband & I often have had to escape our home just to breathe! We are an older healthy couple married many decades. For after they spray I can barely think or feed my husband -let alone clean our home. The barely living is what I've become in a pesticide polluted atmosphere. I can go outside only for a few minutes and that only with the use of a respirator.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.