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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-3212
2. Registrant Information.
Registrant Reference Number: PROSAR Case #: 1-26485403
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.
13-JUN-115. Location of incident.
Country: CANADA
Prov / State: ALBERTA
6. Date incident was first observed.
13-JUN-11Product 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. 27800 PMRA Submission No. EPA Registration No.
Product Name: Killex Ready to Use Lawn Weed Control
- Active Ingredient(s)
- 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)
- DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, OR SODIUM SALT)
- MECOPROP-P (PRESENT AS DIMETHYLAMINE SALT)
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
- Respiratory System
- Symptom - Shortness of breath
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)
Drift from the application site
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.
Respiratory
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
>8 hrs <=24 hrs / > 8 h < = 24 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.)
1-26485403- The reporter indicated she was exposed to an herbicide containing the active ingredients 2,4-D ( dimethylamine salt), mecoprop-p (propionic acid), and dicamba (dimethylamine salt). The reporter indicated her husband was spraying he product on their residential lawn five days prior to her initial contact with the registrant. She reported she was standing 'downwind' while the product was being sprayed. She does not describe a discreet exposure incident. She stated later the same day of the application she experienced shortness of breath. The reporter indicated the symptoms had improved since the described exposure but had not fully resolved. The reporter was advised of the potential respiratory irritant effect of the product when exposed by that avenue. She was advised that symptoms may be exaggerated in patients with underlying respiratory disease or smokers like herself. She was advised if the symptoms persisted she should seek medical advice to alleviate her discomfort. Care would be primarily symptomatic. The reporter was not available for follow up. No further information is available.
To be determined by Registrant
14. Severity classification.
Moderate
