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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-3476

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: QUEBEC

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. 31457      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).

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.


2. Demographic information of data subject

Sex: Female

Age: >1 <=6 yrs / > 1 < = 6 ans

3. List all symptoms, using the selections below.


  • General
    • Symptom - Swelling
  • Skin
    • Symptom - Blister
  • General
    • Symptom - Other
    • Specify - Allergic reaction
  • Gastrointestinal System
    • Symptom - Vomiting

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?


Hour(s) / Heure(s)

7. Exposure scenario


8. How did exposure occur? (Select all that apply)

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.)

Après 2 minutes exposé à linsecticide, ma fille s'est mise à enfler rapidement sur les zone touchées. 2 minutes après elle s'est mise à faire des cloques. Nous l'avons mise sous la douche rapidement mais ses oreilles et son visage s'est mis à enfler rapidement, ses oreilles 3x leur grosseur. Nous avons administré 2 doses de benadryl. La réaction allergique s'est répandue sur tout son corps. Nous nous sommes dirigés vers l'hôpital le plus près. Nous avons du contacter le 911 sur la route, car elle s'est mise à vomir (2 fois). Les premiers répondants lui ont donné de l'oxygène et de l'epinephrine. Lors de l'arrivée des ambulanciers, ils lui en ont redonner 2 fois pendant la route vers l'urgence. Nous sommes restés en observation aux soins intensifs pendant 4h.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.