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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2007-5946
2. Registrant Information.
Registrant Reference Number: PROSAR Case 1-15125259
Registrant Name (Full Legal Name no abbreviations): Scotts Canada Ltd
Address: 2000 Argentia Road, Plaza 5, Suite 101
City: Mississauga
Prov / State: Ontario
Country: USA
Postal Code: L5N2R7
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
19-JUL-075. Location of incident.
Country: CANADA
Prov / State: MANITOBA
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. PMRA Submission No. EPA Registration No.
Product Name: Killex Unknown
- 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 AMINE SALTS)
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: Male
Age: >64 yrs / > 64 ans
3. List all symptoms, using the selections below.
System
- General
- Symptom - Swelling
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
Non-occupational
8. How did exposure occur? (Select all that apply)
Contact with treated area
What was the activity? Walking with Bare feet
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.
>1 wk <=1 mo / > 1 sem < = 1 mois
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.)
History: Caller states he has been using product for a number of years on his lawn. Caller states he uses product 1-2x / year. Caller states while working in yard caller walks with bare feet over treated grass. Caller states he has had an inflammatory condition in his low legs and feet that has been getting worse over the last couple of months. Caller states product was recently applied approx 2wks ago. Caller states after walking on lawn with bare feet 5days after application his inflammation has gotten worse. Caller describes symptoms as "the muscles in his ankles and on the bottom of his feet feel firm." Caller verifies there is no dermal irritation to the bottom of his feet. Caller states he has been seen by a MD physician and physician believes his inflammation is nerve related. Caller is wondering if product could cause his symptoms. Assessment: Not an anticipated result of product exposure. Product can be a dermal irritant with short term exposure and can cause neurological and muscular problems with repeated and long-term exposure. Based upon the history given I believe something else is going on and I recommend you continue to work with your MD physician to find the cause of your symptoms. CB prn. Note: PMRA: Based on the toxicologic profile of the product and the alleged contact/effect in the incident description, the symptoms alleged would be inconsistent with what would be expected from the described product contact.
To be determined by Registrant
14. Severity classification.
Moderate
