Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-3826
2. Registrant Information.
Registrant Reference Number: PROSAR Case #: 1-23430937
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.
Human
4. Date registrant was first informed of the incident.
13-JUL-10
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
13-JUL-10
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. 9167
PMRA Submission No.
EPA Registration No.
Product Name: Ant-B-Gon Max Ant Killer Liquid
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Res. - In Home / Rés. - à l'int. 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 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)
Contact with treated area
Amount of time between application and contact 6
Hour(s) / Heure(s)
What was the activity? habitation the application area
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
Unknown
10. Route(s) of exposure.
Unknown
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.)
1-23430937- The reporter calls to indicate exposure to an insecticide containing the active ingredient borax. The caller states the product was applied by a family member to an entryway in a residential home. The caller indicates six hours later she passed through that area and noted nausea. The caller also indicated she was pregnant. No discreet exposure was described. The caller was advised of the low order of toxicity and wide margin of safety of the product when used according to label directions. She was advised occasionally individuals can respond in a nonspecific way to aromas associated with household products. Symptoms such as nausea can occur in such circumstances which are self-limiting and typically resolve following the removal of the odor. Pregnancy may make you more sensitive to odors or presence of chemicals. The caller was advised to consult her physician for further recommendations. No further information is available.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.