Health Canada
Symbol of the Government of Canada
Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-5227

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-24065786

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: UNKNOWN

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

  • 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: Pub. Area - Indoor/Zone publique - int

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?


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.


  • Skin
    • Symptom - Tingling skin
    • Symptom - Erythema
    • Symptom - Irritated skin
  • Eye
    • Symptom - Irritated eye
  • Respiratory System
    • Symptom - Irritated nose
    • Specify - Nasal irritation
  • General
    • Symptom - Pain

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.)

1-24065786- The reporter indicates she may have been exposed to an insecticide containing the active ingredient dichlorvos. The caller indicates on the advice of a pest control company her employer used the product, an insecticidal strip, to control bed bugs. She, under the instructions of her employer placed the product in plastic bags with books and other materials to be sealed for a period of 72 hours. The strips were also hung in other areas of her workplace. The caller reports her skin did not come in contact with the product. Following removal from the plastic bags the items were returned to the workplace. The caller reported the product could be smelled in the workplace. Over the next two weeks she developed tingling skin, erythema, dermal irritation, ocular irritation, nasal irritation, and abdominal pain. She had seen a physician 09/08/10, two days prior to her initial contact with the registrant, for the reported symptoms. She was evaluated and discharged without treatment. She was advised by her doctor to not return to work for one week. The caller was advised the symptoms encountered were more consistent with dermal and respiratory irritation than potential toxicity. She was advised to continue to work with her physician to alleviate her discomfort. The caller did not provide her contact information for routine follow up. No further information is available.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.