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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 802-509

Product Name: Lilly Miller Moss Out! For Lawns Concentrate

• Active Ingredient(s)

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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 - Diarrhea

• General
  • Symptom - Joint pain

• Gastrointestinal System
  • Symptom - Nausea
  • Symptom - Loss of appetite

• General
  • Symptom - Fatigue

• Skin
  • Symptom - Rash

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

• Skin
  • Symptom - Rash

• Nervous and Muscular Systems
  • Symptom - Headache

• General
  • Symptom - Joint pain

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
  • Symptom - Seizure

• General
  • Symptom - Weakness
  • Symptom - Lethargy

• Nervous and Muscular Systems
  • Symptom - Ataxia

• Eye
  • Symptom - Nystagmus

• Gastrointestinal System
  • Symptom - Loss of appetite
  • Specify - Inappetence

• Nervous and Muscular Systems
  • Symptom - Disorientation

• Gastrointestinal System
  • Symptom - Diarrhea

• Nervous and Muscular Systems
  • Symptom - Other
  • Specify - Still not fully mobile

• General
  • Symptom - Pain

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.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Not Applicable

19. Provide supplemental information here