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Sécurité des produits de consommation

Déclaration d'incident

Sous-formulaire I: Renseignements généraux

1.Type de rapport.

Nouvelle déclaration d'incident

No de la demande: 2011-3678

2. Renseignements concernant le titulaire.

Numéro de référence du titulaire d'homologation: x

Nom du titulaire (nom légal complet, aucune abbréviation): x

Adresse: x

Ville: x

État: x

Pays: x

Code postal /Zip: X

3.Choisir le (les) sous-formulaire(s) correspondant à l'incident.

Incident chez l'humain

4. Date à laquelle le titulaire d'homologation a été informé pour la première fois de l'incident.


5. Lieu de l'incident.



6. Date de la première observation de l'incident.


Description du produit

7. a) Donner le nom de la matière active et, si disponibles, le numéro d'homologation et le nom du produit (incluant tous les mélanges). Si le produit n'est pas homologué, donner le numéro de la demande d'homologation.

Matière(s) active(s)

ARLA No d'homologation 24723      ARLA No de la demande d'homologation       EPA No d'homologation.


  • Matière active

7. b) Type de formulation.

Renseignments sur l'application

8. Est-ce que le produit a été appliqué?


9. Dose d'application.


Unités: g

10. Site d'application (choisir tout ce qui s'applique).

Site: Personal use / Usage personnel

Specify Type: arm

11. Donner tout renseignement additionnel concernant l'application (comment le produit a été appliqué, la quantité utilisée, la superficie de la zone traitée, etc.)

Aerosol can, used this product for years and always just sprayed it on. Bought two cans as last year there was none available come holiday season. First can used half and left it in my outher tractor, broke this one out as it was in a dry dark storage room and wanted it in my outher baler tractor. Started to spray my arm down as I walked towards my tractor maybe 5 grams out totally, but can weigh the can as I'm not using it and any one is welcome to come take a small sample or be a guinea pig and I sprayed it on there arm. ps. we need to know what to hell is in here, maybe seconds as it spit out in small spats and I thought okay, I put some on my outher arm then wipe it, I had just got the first little bit on my outher arm and I could see holes going into my flesh fast on my left arm I ran to the house as directions said if any allergy or problems just wash immediately with soap and water, which I did three or four times it was clear to me by night time my holes were getting bigger in my flesh so I was worried about infection so sprayed some stuff on it, by morning it hurt like hell, still washing with soap, I could not get it to stop eating my flesh,

À être déterminé par le titulaire

12. Selon vous, le produit a-t-il été utilisé en conformité avec le mode d'emploi de L'étiquette?


Sous-formulaire II : Incident chez l'humain (Obligation d'utiliser un formulaire séparé pour chaque personne affectée)

1. Source de la déclaration.

Personne affectée

2. Renseignement démographique sur la personne affectée

Sexe: Homme

Âge: Unknown / Inconnu

3. Énumérez tous les symptômes, au moyen des choix suivants.


  • Peau
    • Symptôme - Brûlures (au 2ème ou 3ème degré)

4. Quelle a été la durée des symptômes?

>1 wk <=1 mo / > 1 sem < = 1 mois

5. La personne affectée a-t-elle reçu des soins médicaux? Donner les détails à la question 13.


6. a) Est-ce que la personne a été hospitalisée?


6. b) Pendant combien de temps?

7. Scénario d'exposition


8. Comment l'exposition s'est-elle produite? (cocher tout ce qui s'applique)


9.Si l'exposition s'est produite lors du traitement ou au moment du retour dans la zone traitée, de l'équipement de protection individuelle était-il porté? (cocher tout ce qui s'applique)


10. Voie(s) d'exposition.


11.Durée de l'exposition?

<=15 min / <=15 min

12.Temps écoulé entre l'exposition et l'apparition des symptômes.

<=30 min / <=30 min

13.Donner tout détail additionnel au sujet de l'incident (p.ex. description des symptômes tels que la fréquence et la gravité, type de soins médicaux, résultats des tests médicaux, quantité de pesticide à laquelle la personne a été exposée, etc.)

(continued) You have to understand I am out on a ranch and I have been sent to the hospital with bones sticking out of my arm and sent back home, that's how bad our doctor situation is and I learrned a lot in the last 50 years. I know I have to do some thing immediately to stop this, and resulted in putting baking soda on it as I know baking soda neutralises any forms of acid and that appeared to me exactly what it was doing, that did finally stop it after two applications, but now have deep holes eating into my arm, then put a dry application of silver on as I know from being in the burn centre they still use that as that is what they sent me home with a salve, and still had some, it wasn't until I went to my brother in laws place for a wedding shower. He said get on the phone and tell these people and if it still doesn't heal get into a medical doctor, he took pictures and that was like three weeks later, I immediately called the number on the can when I got home it was the 18, they then transfered me to there toxicologist and she ? Let me finish, she said keep it open and see medical doctor that's easier said that done out here, anyway I took pictures myself that day only one or two open left, rest are healing. I wish I had taken pictures the first 30 minutes as it was actively eating holes in my arm but who thinks of that, my brother in law concerns was younger people of age 10 or over getting this and maybe even getting some on in even more dangerous places of the body, there is either acid in this one can or a misplaced bug killer chemical or some thing very serious and wrong with what went into that can, as any fool knows it was not an allergy or just a reaction or rash. Haven't heard back from them, I also just a few days ago complained on their web site, if they want to be the leading brand of bug repellant they better dam well get on this or it's going on the internet everywhere. I also phoned Walmart where I bought it and talked to the manager. He said go straight to Johnson as they are only a retailer, fine I did that. I work from 5am till 10pm at night seven days a week as I run my ranch myself and I have had a lot to do with chemicals, I have never seen anything like this period. (name) still have scars and one small open and I have both cans, just wasn't getting caught like last year and could get none this years. (number), July 18 3:24pm Reference number#, my cans batch numbers are one that did the damage is J0 83 72944 1336 74, and only a few grams used like 5 as it immediately started eating my flesh in seconds. Outher can is same batch number and used approximately 1/2 of it with no problems can. I have no problems sending my pics but they are on 16 and just yesterday, and I have no problems with someone coming and taking a sample out of that.

À être déterminé par le titulaire

14. Classification selon la gravité.

15. Donner des renseignements additionnels ici.