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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-5220
2. Registrant Information.
Registrant Reference Number: PROSAR Case # 1-23965809
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.
31-AUG-105. Location of incident.
Country: CANADA
Prov / State: NEW BRUNSWICK
6. Date incident was first observed.
30-AUG-10Product 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. 27201 PMRA Submission No. EPA Registration No.
Product Name: Ant-B-Gon Max Ant Eliminator
- Active Ingredient(s)
- PERMETHRIN
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. - 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 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.
System
- Nervous and Muscular Systems
- Symptom - Numbness
- Gastrointestinal System
- Symptom - Vomiting
- Cardiovascular System
- Symptom - Hypertension
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)
Unknown
10. Route(s) of exposure.
Unknown
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
>2 hrs <=8 hrs / > 2 h < = 8 h
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.)
1-23965809- The reporter calls to indicate he was possibly exposed to an insecticide containing the active ingredient permethrin. The caller described application of the product to his property outside his residence the day prior to the initial contact with the registrant. The caller indicated he knew of no exposure, was very cautious, and washed his skin thoroughly after use of the product. He reported he developed the symptoms of dermal numbness (on his face and down his arms) and vomiting. The reporter indicated he had gone to the emergency room the night prior to the initial contact with the registrant. The caller indicated they had run a ¿¿¿cardiogram? that was within normal limits. The doctor that examined him was told of the potential exposure and did not think his symptoms were related. The cause of his symptoms was not discovered at the emergency room. The caller was advised that the symptoms seen would not be expected following routine use of the product according to the label. It was recommended the caller consult his doctor. On routine follow up the reporter indicated he was diagnosed with high blood pressure, a new diagnosis. He did not clarify if any treatment was recommended, but stated he was ¿¿¿fine? now. No further information is available.
To be determined by Registrant
14. Severity classification.
Moderate
