Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2024-2135
2. Registrant Information.
Registrant Reference Number: Foray 48B Incident 05-22-2024
Registrant Name (Full Legal Name no abbreviations): Valent BioSciences LLC
Address: 1910 Innovation Way
City: Libertyville
Prov / State: IL
Country: USA
Postal Code: 60048
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
23-MAY-24
5. Location of incident.
Country: CANADA
Prov / State: BRITISH COLUMBIA
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)
PMRA Registration No. 24977
PMRA Submission No.
EPA Registration No.
Product Name: Foray 48B Biological Insecticide Aqueous Suspension
- Active Ingredient(s)
- BACILLUS THURINGIENSIS SUBSPECIES KURSTAKI (ALL STRAINS)
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
4
Units: L/ha
10. Site pesticide was applied to (select all that apply).
Site: Pub. Area - Outdoor/Zone publique - ext
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?
Yes
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: Female
Age: >64 yrs / > 64 ans
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
- Eye
- Symptom - Other
- Specify - Posterior vitreous detachment
- Eye
- Symptom - Other
- Specify - Floaters
- Symptom - Other
- Specify - Flashes
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Yes
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)
None
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.)
Flew over my house several times. Totally confused when driving to [Retailer], drove into a curb in parking lot. Resting in bed. Aircraft flew over house several times. Stayed indoors whole day. Feel very off. Had to go to optometrist and was diagnosed with a Posterior Vitreous Detachment (PVD). Has lots of sensitivities and allergies; symptoms showed up right after spray, drove like she was drunk. In bed for three days. Fatigued. [Age] yr. female. Had clean eye report prior to this issue. Irritated eyes that she rinsed repeatedly. Had floaters and saw flashes. Wants follow up call with notification of next treatment. Wants to know if we will pay for hotel.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.