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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2024-0619

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. 33424      PMRA Submission No.       EPA Registration No.


  • Active Ingredient(s)

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: Res. - In Home / Rés. - à l'int. maison

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

On September 11th, 2023 I returned to my apartment late in the evening and noticed a very strong, foul smell in my apartment. Additionally, my apartment door was unlocked. I was unsure what had happened and thought a rat or mouse had somehow gained entry and died. As I searched my apartment for the source of the smell I noticed that items I kept on top of my fridge were moved away, the fridge was off centre, and my stove was pulled out from the corner. I communicated with other tenants and said that I thought that someone entered my apartment and I wasn't given notice. Over the next 24 hours I learned from some neighbours that they received notice of spraying weeks prior, were told to vacate their apartment, and prepare their apartment for spraying. My landlord ignored my request for information. I got the contact information from other tenants about the company applying the chemicals and the owner said two (2) chemicals were applied in my apartment: (1) Seclira Cockroach Gel Bait Reservoir (composition: dinotefuran, glycerol, and silica ) & (2) Dragnet FT EC (active ingredient: permethrin).

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: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.


  • Respiratory System
    • Symptom - Coughing
  • General
    • Symptom - Insomnia
  • Respiratory System
    • Symptom - Sore throat
    • Symptom - Other
    • Specify - Raw throat
  • Nervous and Muscular Systems
    • Symptom - Headache
  • General
    • Symptom - Pain
  • Nervous and Muscular Systems
    • Symptom - Other
    • Specify - Pressure
  • Eye
    • Symptom - Photophobia
    • Symptom - Other
    • Specify - Pain
  • General
    • Symptom - Loss of balance
  • Nervous and Muscular Systems
    • Symptom - Staggering

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)

Contact with treated area


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.

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.)

The night of September 11th, 2023 I coughed heavily and I could barely sleep; I spent several hours awake and coughing from the chemicals. My throat became raw and sore. The night and into the next day (early morning) I developed a severe headache. Over the course of the day (while working) the pain was excruciating. I contemplated presenting to hospital and asking doctors to drill a hole into my skull to relieve the pain and pressure. I developed photophobia and found exposure to normal natural lighting and artificial lighting created significant ocular and cranial pain. I needed to take a few hours in the middle of the day away from work, shield my eyes from any light, and lay down. This did not significantly alleviate the pain My balance was negatively affected; I was stumbling during the day and people I worked with inquired if I was okay when I stumbled in front of them. I called my doctor on September 13th, 2023 and was able to get a telephone appointment that day. I described some of the symptoms and called the doctor's office again when I remembered that I forgot to mention some symptoms (called back on September 20th, 2023). When I spoke with my healthcare provider I reported that symptoms appeared to be alleviating relative to Monday and I was offered prescription. I declined a prescription (due to side effects and cost) and opted to limit my time in my home until the smell and symptoms receded. I altered the amount of work that I did for a few days, and altered the time in my own home.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.