Déclaration d'incident

Sous-formulaire I: Renseignements généraux

1.Type de rapport.

Nouvelle déclaration d'incident

No de la demande: 2019-1339

2. Renseignements concernant le titulaire.

Numéro de référence du titulaire d'homologation: 2019-9c

Nom du titulaire (nom légal complet, aucune abbréviation): BASF Canada Inc.

Adresse: 100 Milverton Drive 5th Floor

Ville: Mississauga

État: Ontario

Pays: Canada

Code postal /Zip: L5R 0E4

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.

28-FEB-19

5. Lieu de l'incident.

Pays: CANADA

État: ONTARIO

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

22-FEB-19

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)

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ARLA No d'homologation 28485      ARLA No de la demande d'homologation       EPA No d'homologation.

Nom du produit: 221 Residual Insecticide

• Matière active
  • LAMBDA-CYHALOTHRIN

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ARLA No d'homologation 30075      ARLA No de la demande d'homologation       EPA No d'homologation.

Nom du produit: Bedlam

• Matière active
  • D-PHENOTHRIN
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE

---

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

Nom du produit: Temprid

• Matière active
  • BETA-CYFLUTHRIN
  • IMIDACLOPRID

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7. b) Type de formulation.

Renseignments sur l'application

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

Oui

9. Dose d'application.

Inconnu

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

Site: Res. - In Home / Rés. - à l'int. maison

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

221 Residual insecticide was applied with Temprid around the baseboards. Bedlam was sprayed on the couch,

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?

Inconnu

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

1. Source de la déclaration.

Professionnel de la santé

2. Renseignement démographique sur la personne affectée

Sexe: Homme

Âge: >12 <=19 yrs / >12 <=19 ans

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

Système

• Systèmes nerveux et musculaire
  • Symptôme - Douleur musculaire

• General
  • Symptôme - Autre
  • Specify - Exacerbation of Fuzzy head/ buzzing in head

• Systèmes nerveux et musculaire
  • Symptôme - Difficulté de marcher
  • Symptôme - Mal de tête

4. Quelle a été la durée des symptômes?

Unknown / Inconnu

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

Non

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

Non

6. b) Pendant combien de temps?

7. Scénario d'exposition

Non professionnel

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)

Aucun

10. Voie(s) d'exposition.

Inconnu

11.Durée de l'exposition?

Unknown / Inconnu

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

>30 min <=2 hrs / >30 min <=2 h

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.)

From report: Caller and 2 sons have multiple medical conditions and all 3 have sensitivities to chemicals and fragrances. Yesterday a pest control company use this product along with 2 other unknown products in caller's apartment. She waited for 7 hours and then returned home with both children. The product was dry but she noticed an odor. Within a couple of hours caller developed a headache, cough,dizziness, resting heart rate elevation (120 bpm), shakiness and became more forgetful. These symptoms have persisted in differing severity. She slept on a couch that is believed to have had this product used on it. Her sons also stayed in the home. One has been drowsy and maybe confused. He is just not acting himself. The other son has a preexisting condition that is described as a fuzzy/buzzing in his head. This condition has worsened as he has reentered the home. He has also been dealing with headaches, trouble walking and his muscles are more sore than usual. Caller states that they have had similar reactions before in similar situations but this time their symptoms are worse then expected. She states that even Tylenol has not helped her headache. She is in the process of finding out what the 2 other product are. Caller would like to know of any poisoning concerns and what to do. She states that they are planning on coming back and using the product again. They have not left the home at this point and have not called their physician. Follow up call: Callback completed. Spoke to the initial caller. She reports that she found information about the other products that were used in the home, Bedlam was sprayed on the couch, and Temprid was used around the baseboards along with the 221 Residual Spray product. She continues to have symptoms inside her home, but the symptoms dissipate when she leaves. She has been in contact with the PCP,and they have given her instructions to reduce their exposure to the products. She has not sought medical attention, but plans to speak to their physician about possible effects from their exposure.

À être déterminé par le titulaire

14. Classification selon la gravité.

Modérée

15. Donner des renseignements additionnels ici.

Source of report is family member of data subject. As per report, specialist stated "There is not typical or expected reactions to use of the product. As long as the product was dry and ventilated we would not expect any symptoms to develop. However, different people can have different sensitivities to different products and sometimes unusual thing can happed..."

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: Femme

Âge: >19 <=64 yrs / >19 <=64 ans

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

Système

• Système cardiovasculaire
  • Symptôme - Fréquence cardiaque anormallement élevée

• Système gastro-intestinal
  • Symptôme - Nausée

• Systèmes nerveux et musculaire
  • Symptôme - Mal de tête

• General
  • Symptôme - Autre
  • Specify - Forgetfulness

• Systèmes nerveux et musculaire
  • Symptôme - Étourdissement

• Système respiratoire
  • Symptôme - Toux

• Systèmes nerveux et musculaire
  • Symptôme - Agitation
  • Symptôme - Tremblement

4. Quelle a été la durée des symptômes?

Unknown / Inconnu

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

Non

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

Non

6. b) Pendant combien de temps?

7. Scénario d'exposition

Non professionnel

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)

Aucun

10. Voie(s) d'exposition.

Inconnu

11.Durée de l'exposition?

Unknown / Inconnu

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

>30 min <=2 hrs / >30 min <=2 h

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.)

From report: Caller and 2 sons have multiple medical conditions and all 3 have sensitivities to chemicals and fragrances. Yesterday a pest control company use this product along with 2 other unknown products in caller's apartment. She waited for 7 hours and then returned home with both children. The product was dry but she noticed an odor. Within a couple of hours caller developed a headache, cough,dizziness, resting heart rate elevation (120 bpm), shakiness and became more forgetful. These symptoms have persisted in differing severity. She slept on a couch that is believed to have had this product used on it. Her sons also stayed in the home. One has been drowsy and maybe confused. He is just not acting himself. The other son has a preexisting condition that is described as a fuzzy/buzzing in his head. This condition has worsened as he has reentered the home. He has also been dealing with headaches, trouble walking and his muscles are more sore than usual. Caller states that they have had similar reactions before in similar situations but this time their symptoms are worse then expected. She states that even Tylenol has not helped her headache. She is in the process of finding out what the 2 other product are. Caller would like to know of any poisoning concerns and what to do. She states that they are planning on coming back and using the product again. They have not left the home at this point and have not called their physician. Follow up call: Callback completed. Spoke to the initial caller. She reports that she found information about the other products that were used in the home, Bedlam was sprayed on the couch, and Temprid was used around the baseboards along with the 221 Residual Spray product. She continues to have symptoms inside her home, but the symptoms dissipate when she leaves. She has been in contact with the PCP,and they have given her instructions to reduce their exposure to the products. She has not sought medical attention, but plans to speak to their physician about possible effects from their exposure.

À être déterminé par le titulaire

14. Classification selon la gravité.

Modérée

15. Donner des renseignements additionnels ici.

As per report, specialist stated "There is not typical or expected reactions to use of the product. As long as the product was dry and ventilated we would not expect any symptoms to develop. However, different people can have different sensitivities to different products and sometimes unusual thing can happed..."

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

1. Source de la déclaration.

Autre

2. Renseignement démographique sur la personne affectée

Sexe: Homme

Âge: >12 <=19 yrs / >12 <=19 ans

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

Système

• Systèmes nerveux et musculaire
  • Symptôme - Confusion

• General
  • Symptôme - Somnolence
  • Symptôme - Lethargie
  • Symptôme - Comportement anormal

4. Quelle a été la durée des symptômes?

Unknown / Inconnu

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

Non

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

Non

6. b) Pendant combien de temps?

7. Scénario d'exposition

Non professionnel

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)

Aucun

10. Voie(s) d'exposition.

Inconnu

11.Durée de l'exposition?

Unknown / Inconnu

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

>30 min <=2 hrs / >30 min <=2 h

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.)

From report: Caller and 2 sons have multiple medical conditions and all 3 have sensitivities to chemicals and fragrances. Yesterday a pest control company use this product along with 2 other unknown products in caller's apartment. She waited for 7 hours and then returned home with both children. The product was dry but she noticed an odor. Within a couple of hours caller developed a headache, cough,dizziness, resting heart rate elevation (120 bpm), shakiness and became more forgetful. These symptoms have persisted in differing severity. She slept on a couch that is believed to have had this product used on it. Her sons also stayed in the home. One has been drowsy and maybe confused. He is just not acting himself. The other son has a preexisting condition that is described as a fuzzy/buzzing in his head. This condition has worsened as he has reentered the home. He has also been dealing with headaches, trouble walking and his muscles are more sore than usual. Caller states that they have had similar reactions before in similar situations but this time their symptoms are worse then expected. She states that even Tylenol has not helped her headache. She is in the process of finding out what the 2 other product are. Caller would like to know of any poisoning concerns and what to do. She states that they are planning on coming back and using the product again. They have not left the home at this point and have not called their physician. Follow up call: Callback completed. Spoke to the initial caller. She reports that she found information about the other products that were used in the home, Bedlam was sprayed on the couch, and Temprid was used around the baseboards along with the 221 Residual Spray product. She continues to have symptoms inside her home, but the symptoms dissipate when she leaves. She has been in contact with the PCP,and they have given her instructions to reduce their exposure to the products. She has not sought medical attention, but plans to speak to their physician about possible effects from their exposure.

À être déterminé par le titulaire

14. Classification selon la gravité.

Modérée

15. Donner des renseignements additionnels ici.

Source of report is family member of data subject. As per report, specialist stated "There is not typical or expected reactions to use of the product. As long as the product was dry and ventilated we would not expect any symptoms to develop. However, different people can have different sensitivities to different products and sometimes unusual thing can happed..."