Health Canada
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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2024-2332
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.
Human
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.
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.
Liquid
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
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?
Unknown
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
- General
- Symptom - Fatigue
- Respiratory System
- Symptom - Runny nose
- Symptom - Respiratory congestion
- Symptom - Sore throat
- Skin
- Symptom - Itchy 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
Unknown
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.)
I've been having cold like symptoms for a couple weeks now. Starting two weeks ago from June 2nd. Fatigue, runny nose, congestion, sore throat, itchy skin. Symptoms seem to line up with when the spray happened.
