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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-5367

2. Registrant Information.

Registrant Reference Number: Prosar 1-20781131

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.


4. Date registrant was first informed of the incident.


5. Location of incident.

Country: CANADA

Prov / State: NOVA SCOTIA

6. Date incident was first observed.


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.


PMRA Registration No. 22027      PMRA Submission No.       EPA Registration No.

Product Name: Home Defense Max No-Pest Insecticidal Strip (Ortho)

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


10. Site pesticide was applied to (select all that apply).

Site: Other / Autre

Préciser le type: Vehicle

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

The product was applied inside a van on 11/17/2009.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?


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: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.


  • Gastrointestinal System
    • Symptom - Nausea
  • Skin
    • Symptom - Flushed
    • Symptom - Tingling skin
  • Eye
    • Symptom - Other
    • Specify - "Twitching"

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


8. How did exposure occur? (Select all that apply)


9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)


10. Route(s) of exposure.


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.)

1-20781131: A reporter called on 11/19/2009 to report his exposure to an insecticide containing the active ingredient Dichlorvos. According to the reporter, the product was applied inside his van on 11/17/2009. He got into the van on 11/18/2009 and developed nausea, lip tingling, eye twitching, and flushed skin. He removed the product from the van and opened the windows. Just prior to the report, the reporter got into the van again and experienced the same effects, but to a lesser degree. The reporter was advised that the odor of the product may result in signs of nausea, headache, and respiratory irritation. The signs are typically transient and subside with removal from the source of the odor. A recommendation was made to ventilate the van by leaving the windows open and running a fan if necessary. Surfaces may be washed with a household cleaner. A recommendation was also made to seek medical evaluation should the signs persist or worsen. An attempt at follow up was unsuccessful. No further information was obtained.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.