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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-1833

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-25439480

Registrant Name (Full Legal Name no abbreviations): The Scotts Company LLC

Address: 14111 Scottslawn Road

City: Marysville

Prov / State: Ohio

Country: USA

Postal Code: 43041

3. Select the appropriate subform(s) for the incident.


4. Date registrant was first informed of the incident.


5. Location of incident.


Prov / State: VIRGINIA

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.       PMRA Submission No.       EPA Registration No. Unknown

Product Name: Sevin (Non-specific)

  • Active Ingredient(s)
      • Unknown

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: 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?


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: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • Nervous and Muscular Systems
    • Symptom - Muscle weakness
  • Renal System
    • Symptom - Lack of control of urination
  • General
    • Symptom - Other
    • Specify - "immune problem" (nonspecific)

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)

Contact with treated area

What was the activity? The patient inappropriately applied the product inside her home

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.)

1-25439480- The caller indicates possible exposure of a family member to an insecticide containing the active ingredient carbaryl. The reporter indicates they are a ¿¿¿distant in-law? of the patient, a female of unknown demographics. The family member had indicated the patient was hospitalized with the symptoms of muscle weakness in the legs and hands. She also had loss of bladder control. The caller indicated the patient had used the product (which was not identified with any certainty) at an unknown time frame in her home on the flooring in sufficient quantity to be visible on her bedding. On routine follow up the caller indicated the family member/patient was still in the hospital (ICU). She had been diagnosed with ¿¿¿trouble with her antibodies? according to the caller. The caller indicated the treating physician had indicated the product may have played a role in development of symptoms, but was not the primary cause for the patient¿¿¿s illness. The caller was advised that this product was not designed or labeled for indoor use. On yet another call back the reporter indicated the patient was out of the hospital and had been diagnosed with an ¿¿¿autoimmune disorder?. Medication had been dispensed and the patient is being referred to a neurologist. No further information is available.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.