Health Canada
www.hc-sc.gc.ca
Common menu bar links
Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2007-5948
2. Registrant Information.
Registrant Reference Number: PROSAR Case 1-15154819
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.
27-JUL-075. Location of incident.
Country: CANADA
Prov / State: NOVA SCOTIA
6. Date incident was first observed.
26-JUL-07Product 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. 27207 PMRA Submission No. EPA Registration No.
Product Name: Bug-B-Gon Max Ant & Chinch Bug Eliminator Ready-to-Spray
- Active Ingredient(s)
- CARBARYL
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.
Other
2. Demographic information of data subject
Sex: Male
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Gastrointestinal System
- Symptom - Diarrhea
- Nervous and Muscular Systems
- Symptom - Dizziness
4. How long did the symptoms last?
>3 days <=1 wk / >3 jours <=1 sem
5. Was medical treatment provided? Provide details in question 13.
No
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)
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.
Unknown
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.)
History: Caller states he is calling on behalf of his (age) cousin who is complaining of dizziness and diarrhea that started this morning when he woke up. Caller states yesterday his cousin mixed product in an empty spray bottle, unknown exposure to product. Caller states cousin has been drinking fluids to replaced lost fluids and eating toast. Caller thinks cousin's symptoms could be from something he ate last night too. Caller is wondering if product could have caused his symptoms? Assessment: Not an anticipated result of application. If symptoms persist or worsen over the next 12-24hrs have patient seen by MD physician as I believe something else is going on. CB PRN. 07/30/07 Follow-Up Spoke to (name): He said that he still has some symptoms but they are slowly improving. He did not see an MD as things are improving. Close case Note: PMRA: Based on the toxicologic profile of the product and the temporal relationship to 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
