Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2024-1664
2. Registrant Information.
Registrant Reference Number: X
Registrant Name (Full Legal Name no abbreviations): X
Address: X
City: X
Country: X
3. Select the appropriate subform(s) for the incident.
Human
Domestic Animal
4. Date registrant was first informed of the incident.
5. Location of incident.
Country: CANADA
Prov / State: BRITISH COLUMBIA
6. Date incident was first observed.
06-APR-24
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.
PMRA Submission No.
EPA Registration No. 802-509
Product Name: Lilly Miller Moss Out! For Lawns Concentrate
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).
[company name] (Pest Licence #(redacted)) sprayed Lilly Miller Moss Out! For Lawns Concentrate (EPA No. 802-509) all over the property at (address), an 88-unit pet-friendly apartment building with pet designated outside areas sometime on Saturday, April 6, 2024, as contracted by (company name). Signage was insufficient and no notice to tenants or site manager was given. I was not given the name of the pesticide used until 48 hours after exposure and as such, could not know which First Aid emergency measures to take. I later found out that Lilly Miller Moss out is NOT approved for use in Canada. Had the tenants been informed and/or adequate signage been in place, we could have saved my dog and my son considerable pain and damage. I asked (company name) for the name of the pesticide, so that I could take First Aid measures. Despite the promise of a call back, no one from (company name) contacted me until 24 hours later, on Monday April 8. Upon learning the name of the pesticide, I immediately Googled it, obtained the Safety Data Sheet and took the First Aid measures recommended, which included calling Poison Control.
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.
Other
2. Demographic information of data subject
Sex: Male
Age: >12 <=19 yrs / >12 <=19 ans
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
- Symptom - Headache
- Specify - Migraine
- Gastrointestinal System
- Symptom - Nausea
- Symptom - Loss of appetite
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
No
6. a) Was the person hospitalized?
No
6. b) For how long?
7. Exposure scenario
Non-occupational
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)
Unknown
10. Route(s) of exposure.
Unknown
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.)
My son (age) was exposed and experienced migraines, diarrhea, joint pain, nausea, loss of appetite, skin rashes, and fatigue. It was unknown whether the two of them breathed in the poison, the time of the application.
To be determined by Registrant
14. Severity classification.
15. Provide supplemental information here.
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: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Gastrointestinal System
- Symptom - Loss of appetite
- Nervous and Muscular Systems
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
No
6. a) Was the person hospitalized?
No
6. b) For how long?
7. Exposure scenario
Non-occupational
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)
Unknown
10. Route(s) of exposure.
Unknown
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.)
As I myself experienced the following symptoms: loss of appetite, skin rashes, headaches and joint pain, although my symptoms were not as serious as (son's name) and (dog's name).
To be determined by Registrant
14. Severity classification.
15. Provide supplemental information here.
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Boston Terrier
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
0.92
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Skin
Respiratory
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Nervous and Muscular Systems
- General
- Symptom - Weakness
- Symptom - Lethargy
- Nervous and Muscular Systems
- Gastrointestinal System
- Symptom - Loss of appetite
- Specify - Inappetence
- Nervous and Muscular Systems
- Nervous and Muscular Systems
- Symptom - Other
- Specify - Still not fully mobile
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Not recovered / Non rétabli
16. How was the animal exposed?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
My dog had already had four serious grand mal seizures as a result of the exposure on Saturday afternoon. I kept my dog off the grass for exactly one week, however Saturday night I took her out and she is now sick again. My dog experienced five grand mal seizures, weakness, lethargy, ataxia, nystagmus, inappetence after initial exposure. She experienced nystagmus, disorientation and violent diarrhea after the second exposure. After my dog had already had four serious grand mal seizures as a result of the exposure on Saturday afternoon, I called (company name) at 9:07 am on Sunday, April 7. It was unknown whether the two of them breathed in the poison, the time of application and what pesticide was actually used. I also called Pet poison Control, as recommended by our veterinarian and took (dog's name) to the vet for an exam. Had I been given the name of the pesticide on Sunday when I requested it I could have saved my dog from having any further seizures. It is clear that (dog's name) also brought the pesticides into our unit with her, likely on her paws or fur.
Symptoms resolved upon application of the First Aid measures, although it will take longer for some of (dog name)'s neurological symptoms to fully resolve and it is unknown if the exposure has caused long-term damage that was completely avoidable.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Not Applicable
19. Provide supplemental information here