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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2007-7343
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.
18-JUN-07
5. Location of incident.
Country: CANADA
Prov / State: ALBERTA
6. Date incident was first observed.
09-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. 23446
PMRA Submission No.
EPA Registration No.
Product Name: C-I-L ANT TRAP
7. b) Type of formulation.
Application Information
8. Product was applied?
No
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.
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 - Lesion
- Specify - Laceration
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Unknown
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)
None
10. Route(s) of exposure.
Skin
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
Unknown / Inconnu
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 stated that she was puncturing the ant trap as the instruction call for. The caller decided to use a nail and as she had punctured the one hole the nail went through the product and into her finger. Initially her finger was bleeding, however she was able to get it stopped. The caller could not remember when was the last time she had a tetanus shot. The agency operator advised her to wash the would with soap and water for 15-20 minutes, as well as go in to the emergency department or her family doctor and inquire about a tetanus.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.