Déclaration d'incident

Sous-formulaire I: Renseignements généraux

1.Type de rapport.

Nouvelle déclaration d'incident

No de la demande: 2023-5145

2. Renseignements concernant le titulaire.

Numéro de référence du titulaire d'homologation: 3532556

Nom du titulaire (nom légal complet, aucune abbréviation): Scotts Canada Ltd.

Adresse: 202-6835 Century Ave

Ville: Mississauga

État: ON

Pays: Canada

Code postal /Zip: L5N 7K2

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.

27-FEB-23

5. Lieu de l'incident.

Pays: UNITED STATES

État: ALABAMA

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

23-FEB-23

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

Nom du produit: TomCat Mouse Killer Pre-filled Ready to Use Bait Station

• Matière active
  • BROMETHALIN

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7. b) Type de formulation.

Appât

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.)

Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding application.

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?

Oui

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

• Oeil
  • Symptôme - Irritation de l'oeil

• Système gastro-intestinal
  • Symptôme - Autre
  • Specify - Tongue numb
  • Symptôme - Picotements dans la bouche
  • Specify - Tongue tingling

• General
  • Symptôme - Goût de métal dans la bouche

• Systèmes nerveux et musculaire
  • Symptôme - Autre
  • Specify - Nerve damage

• Oeil
  • Symptôme - Autre
  • Specify - Burning sensation

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.

Inconnu

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)

Application

Quelle était l'activité? Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding the activity

Autre

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.

Respiratoire

11.Durée de l'exposition?

Unknown / Inconnu

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

Unknown / Inconnu

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.)

2/27/2023 Consumer reporting that she experienced her tongue feeling numb and tingly after smelling the odor of the product. The consumer set the trap out on the night of 02/23/23. Immediately she noticed the odor of the product was very strong to her. She states the odor of the product is so strong, that she can taste it in her mouth. She does note that she is highly sensitive to odors, fragrances, and chemicals. On the morning of 02/24/23, she noticed a very small amount of the chunk inside the the station had spilled out onto the floor beside the trap, which she assumed was a sign that a mouse came up to the station. She cleaned up the little bit of crumbs from the floor using disposable gloves. She is positive she did not breathe in any of the powder, but she did notice the odor was still very strong. She denies touching any of the product inside the station directly and she was using disposable gloves when she set out the trap as well. She has not noticed any loose powder from the product, only the few crumbs that fell out that morning. After cleaning up the mess, she called Customer Service to ask them about her tongue being numb and an unknown agent told her that this is normal and some people experience their tongue feeling numb after being overly exposed to the product. Today she called Customer Service again and told them her symptoms have remained constant and unchanged since the night of 02/23/23, so they told her to contact us. Consumer accidentally disconnected while on hold. After being connected back with the consumer, she clarifies that her Depakote is not taken for treatment of seizures and is for an unspecified reason. 3/1/2023 Attempted call back. Left a detailed message requesting a call back. Case and call back numbers provided. 3/2/2023 Attempted call back. No answer. Left message with reason for call, and case and callback numbers. 3/3/2023 Call back: Consumer is returning our call. She states she has not seen her doctor. She reports the symptoms are ongoing. When she spoke with the company they told her some people have reported numbness and tingling with product use. She would like to speak with Customer Service about how long it will last. She stated that she knows the product caused the numbness/tingling. 8/29/2023 Call back from consumer. The caller is inquiring about any prognosis for nerve damage caused by the product. The caller reported that she did experience a burning sensation to the eyes at the time of placement of product and subsided within 5 minutes and that she experienced a metallic taste in mouth that lasted for weeks, but did not know the exact time frame. She is now stating that the product was wet on the floor on 24Feb2023 when she cleaned it up and that she was advised by Customer Service that the product was dangerous if it became wet. The caller stated that she was seen by a specialist a few weeks later as she thought the symptoms would go away. She was seen by an Ear, Nose, & Throat Doctor on 03March2023 and was diagnosed nerve damage by product. The caller believed that the symptoms were from the product and stated that the doctor was 100 percent sure that the product was the cause as well. No further information is available.

À être déterminé par le titulaire

14. Classification selon la gravité.

Majeure

15. Donner des renseignements additionnels ici.

The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews.