Health Canada
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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2019-2776
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.
Environment
4. Date registrant was first informed of the incident.
5. Location of incident.
Country: CANADA
Prov / State: QUEBEC
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. 27227 PMRA Submission No. EPA Registration No.
Product Name: OFF! POWERPAD MOSQUITO LAMP
- Active Ingredient(s)
- D-CIS,TRANS-ALLETHRIN
7. b) Type of formulation.
Other (specify)
lamp, candle, powerpadApplication Information
8. Product was applied?
No
9. Application Rate.
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).
The following was reported: Back in summer 2017, purchased other type of OFF product family - PowerPad, it is a lamp that creates fumes to minimize mosquitoes. Upon placing the product (OFF! POWERPAD MOSQUITO LAMP) on the back patio balcony, it has been observed that plants and flowers were weakened and indicate signs of not fresh or recovery. In few days after, several flowers in flower-pots died and remained in dry condition with no recovery. The product was used anymore as a result of this incident.To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Unknown
Subform IV: Environment (includes plants insects and wildlife)
1. Type of organism affected
Herbaceous Plants / Plante herbacée
2. Common name(s)
Unknown
3. Scientific name(s)
Unknown
4. Number of organisms affected
Unknown
5. Description of site where incident was observed
Fresh water
Terrestrial
Residential
Salt Water
6. Check all symptoms that apply
Death
7. Describe symptoms and outcome (died, recovered, etc.).
The following was reported: We have found that lamp placed on the balcony caused a death to several flowers in area of 0.5 m around. 6 to 9 plants were affected.
8. a) Was the incident a result of (select all that apply)
Unknown
8. b) i) How many times has the product been applied this year?
Unknown
8. b) ii) What was the date of the last application?
Unknown
9. Did it rain
9. a) During application?
Unknown
9. b) Up to 3 days after application?
Unknown
10. a) Was there a buffer zone?
Unknown
10. b) What type?
Terrestrial
10. c) What was the size of the buffer zone?
11. a) Were environmental samples collected and analysed?
Unknown
To be determined by Registrant
12. Severity classification (if there is more than one possible classification, select the most severe)
Minor
