Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2023-6339
2. Registrant Information.
Registrant Reference Number: 6701183
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.
16-JUL-23
5. Location of incident.
Country: CANADA
Prov / State: QUEBEC
6. Date incident was first observed.
15-JUL-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. 27901
PMRA Submission No.
EPA Registration No.
Product Name: Wilson AntOut RTU
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. - 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).
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
No
Subform II: Human Incident Report (A separate form for each person affected)
1. Source of Report.
Other
2. Demographic information of data subject
Sex: Female
Age: >12 <=19 yrs / >12 <=19 ans
3. List all symptoms, using the selections below.
System
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)
Application
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.
Skin
Eye
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
>30 min <=2 hrs / >30 min <=2 h
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.)
Caller stated that daughter had been spraying product the day before. The wind blew product into her face. Daughter washed her skin and rinsed eyes. A couple hours later, her eye was watering. Symptoms have since cleared.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
Caller was advised that eyes could be irrigated for 15 minutes; no ointments or eye drops. Cold compress could be used. Monitor for symptoms. Call back with any further questions or concerns.