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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2635

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-26351928

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: INDIANA

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. 1021-1749-239

Product Name: Ant-B-Gon Dust

  • Active Ingredient(s)
      • Guarantee/concentration .25 %

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: Male

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.


  • Nervous and Muscular Systems
    • Symptom - Headache
  • Cardiovascular System
    • Symptom - Hypertension
  • Respiratory System
    • Symptom - Respiratory irritation
  • Cardiovascular System
    • Symptom - Other
    • Specify - pacemaker and defibulator went off

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.)

1-26351928- The reporter indicates he has been exposed to an insecticide containing the active ingredient permethrin. The (age) male reporter indicates he applied the product to the kitchen in his home the same day of his initial report. He reported later in the day he attempted to vacuum the product with a vacuum cleaner which had a hole in the collection bag. He reports dust was airborne and breathed. He indicated respiratory irritation following the exposure. He also noted hypertension and headache. Lastly, his pacemaker defibrillator 'went off'. In response to his symptoms he called EMS. The emergency responders evaluated him and recommended he return himself to supplemental oxygen he currently uses. The reporter indicated he refused to be transported to the hospital by EMS due to personal financial constraints. The reporter indicated his symptoms had fully resolved at the time of his initial report. The caller was advised of the potential irritant effect of the product when encountered by the respiratory route and that symptoms associated with any respiratory irritant may be pronounced in individuals with underlying respiratory/cardiovascular disease like himself. He was advised avoidance of similar products would be appropriate due to his medical status. No further information is available.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.