Health Canada
Symbol of the Government of Canada
Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-4406

2. Registrant Information.

Registrant Reference Number: PROSAR Case 1-14914904

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.

18-MAY-07

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

13-MAY-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. 24265      PMRA Submission No.       EPA Registration No.

Product Name: KILLEX READY-TO-USE HERBICIDE QUICK CONNECT SPRAY

  • Active Ingredient(s)
    • 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)
    • DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, OR SODIUM SALT)
    • MECOPROP (PRESENT AS DIETHANOLAMINE SALT)
    • MECOPROP (PRESENT AS DIMETHYLAMINE SALT)

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?

Unknown

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Data Subject

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 - Rash
    • Symptom - Itchy skin

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)

None

10. Route(s) of exposure.

Skin

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.)

Patient used the product last Sunday (5/13) and developed a rash a day or so after. Was not wearing long sleeves/pants during application. Has a rash on the top of hands and the tops of feet. These areas are a little bit itchy but not too much. Has used hydrocortisone cream but that did not seem to help. Wondering if this is expected reaction from the product. Patient follow-up information.. Was seen at the clinic and was prescribed 2 different allergy medications, symptoms have resolved.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.