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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2007-7335
2. Registrant Information.
Registrant Reference Number: SJB
Registrant Name (Full Legal Name no abbreviations): Spectrum Brands IP Inc.
Address: P.O. Box 21001
City: Brantford
Prov / State: ON
Country: Canada
Postal Code: N3R 7W9
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
16-AUG-07
5. Location of incident.
Country: CANADA
Prov / State: MANITOBA
6. Date incident was first observed.
20-JUL-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. 25301
PMRA Submission No.
EPA Registration No.
Product Name: WILSON WIPEOUT TOTAL CONCENTRATE WEED & GRASS KILLER
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: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
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?
No
6. b) For how long?
7. Exposure scenario
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.
Eye
11. What was the length of exposure?
<=15 min / <=15 min
12. Time between exposure and onset of symptoms.
<=30 min / <=30 min
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.)
Caller indicated that a fellow employee accidently got some liquid into his eye and has been taken to the local urgent care clinic to get their eye irrigated. They are the local 'eye care center in the area'. Caller requested an MSDS for the product in question along with any other information like how to treat irritation to the eye. The operator who fielded the call indicated that no severe effects expected, however to extend the irrigating from 10mins to 20mins. Patient was sent home from the clinic with drops and was told to follow up with family physician, final outcome unknown.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.