Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2024-0808

2. Registrant Information.

Registrant Reference Number: 6728994

Registrant Name (Full Legal Name no abbreviations): PREMIER TECH LTD.

Address: 1 AVENUE PREMIER

City: RIVIERE-DU-LOUP

Prov / State: QUEBEC

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.

03-OCT-23

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

Unknown

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. 21010      PMRA Submission No.       EPA Registration No.

Product Name: Wilson Jet Foam Wasp and Hornet Spray

• Active Ingredient(s)
  • CHLORPYRIFOS
  • D-TRANS ALLETHRIN
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE

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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. - 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).

Sprayed into the wall to kill wasps 3 weeks before the call.

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.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Numbness

• Skin
  • Symptom - Tingling skin

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

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.)

Caller reported numbness and tingling in toes sometime after exposure, but no further detail was provided.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

The information contained in this report is based on self-reported statements provided to the registrant during telephone interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for as determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interview(s).