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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2007-6522
2. Registrant Information.
Registrant Reference Number: PROSAR Case 1-15218617
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: N1G4Z3
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
15-AUG-075. Location of incident.
Country: CANADA
Prov / State: BRITISH COLUMBIA
6. Date incident was first observed.
28-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. 28258 PMRA Submission No. EPA Registration No.
Product Name: Home Defense Max Perimeter + Indoor Insect Control with Pull N Spray A
- Active Ingredient(s)
- PERMETHRIN
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. - In Home / Rés. - à l'int. 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.
Other
2. Demographic information of data subject
Sex: Male
Age: >64 yrs / > 64 ans
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Rash
- Symptom - Itchy skin
4. How long did the symptoms last?
>1 wk <=1 mo / > 1 sem < = 1 mois
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.
Unknown
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
>3 days <=1 wk / >3 jours <=1 sem
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 her husband applied the product on 7-28-07, "may have gotten some on him." On approx. 8-1-07 he was "broken out with a rash all over arms, back, pelvis, and lips, has bumps that are terribly itchy." States he has "used this product a lot before" with no reaction. Symptoms continue unresolved at this time, patient has spoken with his HCP over the phone regarding the matter, was told the reaction was not due to any of his medications. Assessment: - Direct skin exposure can lead to local irritation (typically a stinging or tingling sensation), however onset of symptoms would be expected to be approximetly 1-2 hrs from exposure, would be expected to improve after washing skin, and would be expected to resolve within 24hrs from exposure. - Recommended caller continue to follow up with HCP for evaluation and treatment. 09/03/2007 Follow-Up Caller said that he is doing fine. He saw his MD and he said that he is allergic to "something" but unsure what. He was given a shot and the rash cleared up about 5-7 days later. Close case Note: 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
