Print | Need Larger Text?

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-3179

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-26394241

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.

Human

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: UNITED STATES

Prov / State: NEW JERSEY

6. Date incident was first observed.

Unknown

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. 2217-570-239

Product Name: Weed-B-Gon Weed Killer for Lawns Conc

• Active Ingredient(s)
  • 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)
    • Guarantee/concentration 3.05 %
  • DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, OR SODIUM SALT)
    • Guarantee/concentration 1.3 %
  • MECOPROP (PRESENT AS AMINE SALT)
    • Guarantee/concentration 10.6 %

7. b) Type of formulation.

Liquid

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?

No

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Female

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Coughing
  • Symptom - Other
  • Specify - Pulmonary Fibrosis

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.

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.)

1-26394241- The reporter indicates exposure of a family member to an herbicide containing the active ingredients mecoprop (dimethylamine salt), 2,4-D (dimethylamine salt), and dicamba (dimethylamine salt). The reporter indicated his (age) mother had sprayed the product undiluted in her yard and some indeterminate time frame preceding the call. The reporter indicates some time frame after (he was unsure of the time frame) she developed a cough and since that point was diagnosed with pulmonary fibrosis. The caller was unable to provide a time line or the results of medical evaluation or what treatments were recommended. The reporter did not describe a discreet exposure incident or provide an avenue of exposure. He asks if the product might be related to his mother¿s diagnosis. The caller was advised of the potential irritant effect of exposure to body surfaces exposed. The caller was advised exposure by any avenue would not be expected to precipitate the reported effect. However, if she had a pre-existing respiratory disorder and was exposed by that avenue the irritant effect may be heightened. The caller did not respond to follow up attempts. No further information is available.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.