Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2007-7395
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
Packaging Failure
4. Date registrant was first informed of the incident.
18-JUN-07
5. Location of incident.
Country: CANADA
Prov / State: SASKATCHEWAN
6. Date incident was first observed.
17-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. 25300
PMRA Submission No.
EPA Registration No.
Product Name: WILSON WIPEOUT TOTAL WEED & GRASS KILLER (RTU)
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
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)
Pesticide Spill
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.
<=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 was holding the bottle in her hands, when the spout came off and some of the contents spilled out onto her hands. She immediately washed her hands with soap and water. However afterwards she started feeling tingling on her skin. no other symptoms reported!
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
Subform VI: Packaging Failure
1. What is the type of packaging that failed?
Spray Bottle / Flacon pulvérisateur
2. Did packaging failure occur during?
Other
specify Handling
3. Did packaging failure result in?
potential exposure
4. Describe how the packaging failed and the surrounding circumstances, including a description of the potential injury or exposure.
Unkown.....the caller stated the spout just cam off
For Registrant use only
5. Provide supplemental information here.
All of our RTU sprayers are tightened down over bottle neck mechanically onto some anti back-off rachets. It is impossible for the nozzle to fall off the bottle unless the nozzle was tampered with.