Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2007-4351
2. Registrant Information.
Registrant Reference Number: 1-14853846
Registrant Name (Full Legal Name no abbreviations): Scotts Canada Ltd.
Address: 2000 Argentia Road, Plaza 5, Suite 101
City: Mississauga
Prov / State: Ontario
Country: Canada
Postal Code: L5N2R7
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
30-APR-07
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
29-APR-07
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. 27201
PMRA Submission No.
EPA Registration No.
Product Name: Ant-B-Gon Max Ant Eliminator
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
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).
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Yes
Subform II: Human Incident Report (A separate form for each person affected)
1. Source of Report.
Other
2. Demographic information of data subject
Sex: Male
Age: >64 yrs / > 64 ans
3. List all symptoms, using the selections below.
System
- Respiratory System
- Symptom - Shortness of breath
- Cardiovascular System
- Symptom - Chest tightness
4. How long did the symptoms last?
>24 hrs <=3 days / >24 h <=3 jours
5. Was medical treatment provided? Provide details in question 13.
Yes
6. a) Was the person hospitalized?
No
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Application
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.
Respiratory
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
>8 hrs <=24 hrs / > 8 h < = 24 h
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.)
Husband sprayed the diluted product outside the house and in the basement on 4/29/07 around 3PM. About 3AM on 4-30-07 he woke up complaining of difficulty breathing and tightness to his chest and throat. He got up and drank some water and felt better, also showered. Now tonight he has the same symptoms, but also as sore throat. He has asthma and has had to use his inhalers more today. Follow-up information Wife states she took her husband to the ER and an MD came in to check him and said he was fine not to worry and he could go home. He has finally started to loose the soreness/tightness in his throat and the MD did not prescribe any therapies or medicines.
To be determined by Registrant
14. Severity classification.
Moderate
15. Provide supplemental information here.