Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-3451
2. Registrant Information.
Registrant Reference Number: PROSAR Case#: 1-23598644
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.
Domestic Animal
4. Date registrant was first informed of the incident.
13-JUN-10
5. Location of incident.
Country: UNITED STATES
Prov / State: MINNESOTA
6. Date incident was first observed.
Unknown
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.
PMRA Submission No.
EPA Registration No. 239-2682
Product Name: Weed-B-Gon MAX Weed Killer RTU
- Active Ingredient(s)
- 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)
- Guarantee/concentration .12 %
- DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, OR SODIUM SALT)
- Guarantee/concentration .05 %
- MECOPROP-P (PRESENT AS AMINE SALT)
- Guarantee/concentration .22 %
7. b) Type of formulation.
Liquid
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Res. - Out Home / Rés - à l'ext.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 III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Bird - Poultry / Oiseau - Volaille
3. Breed
Chicken
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
16. How was the animal exposed?
Other / Autre
specify unknown
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1-23598644- The reporter, an animal owner, indicates exposure of an animal to an herbicide containing the active ingredients 2,4-d, mecoprop-p, and dicamba. The reporter indicates death of a chicken two weeks following use of the product. The reporter does not indicate how the product was used, the mode of exposure, or if any exposure was observed. The caller did not indicate if veterinary assistance was sought or if a necropsy was performed. No further information is available. Death of an animal is unexpected following routine product use.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here