Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-0114

2. Registrant Information.

Registrant Reference Number: PROSAR case #: 1-42511654

Registrant Name (Full Legal Name no abbreviations): Scotts Canada Ltd.

Address: 2000 Argentia Road, Plaza 2, Suite 300

City: Mississauga

Prov / State: Ontario

Country: Canada

Postal Code: L5N1V8

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

20-NOV-15

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

19-NOV-15

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)

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PMRA Registration No. 27520      PMRA Submission No.       EPA Registration No.

Product Name: Ortho Home Defense Max Perimeter/Indoor Insect Control

• Active Ingredient(s)
  • PERMETHRIN

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7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

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.

Medical Professional

2. Demographic information of data subject

Sex: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Red skin
  • Symptom - Tingling skin

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?

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.

Skin

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.)

1-42511654 - The reporter, a physician, indicated that a female patient was exposed to an insecticide containing the active ingredient permethrin. The reporter stated that the patient got some of the product on her skin one day prior to initial contact with the registrant. The patient washed the area immediately after the contact but she did develop some redness on her skin which had resolved by the time of the call. On the day of initial contact the patient was reporting tingling at the site. The reporter was advised that dermal contact may result in short term parasthesia and application of vitamin E oil was recommended to help relieve the symptoms. No additional information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.