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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-4296
2. Registrant Information.
Registrant Reference Number: PROSAR Case # 1-26978487
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.
28-JUL-115. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
28-JUL-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. 27520 PMRA Submission No. EPA Registration No.
Product Name: Home Defense Max Perimeter Indoor Insect Control
- Active Ingredient(s)
- PERMETHRIN
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: Unknown / Inconnu
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
- Nervous and Muscular Systems
- Symptom - Hallucination
- General
- Symptom - Abnormal behaviour
- Specify - speaking in ridiculous manner
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.
>1 wk <=1 mo / > 1 sem < = 1 mois
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.)
1-26978487- The reporter indicates he and a friend may have been exposed to an insecticide containing the active ingredient permethrin. The reporter indicates an adult friend (Subform II, #1) of his used the product two weeks prior to his initial contact with the registrant. The reporter indicated this friend had been experiencing hallucinations and speaking in a 'ridiculous manner' following use of the product. The reporter did not describe the application or the onset of the symptoms seen. The reporter indicated he did not observe exposure but did observe the behavior. The reporter indicated he did personally (Subform II, #2) experience transitory muscle weakness while the previously described patient demonstrated the abnormal behavior. The reporter was advised the observed symptoms would not be expected following exposure to this product by any avenue. He was advised to seek medical assistance in determining the cause of the observed symptoms and if treatment is necessary. No further information is available
To be determined by Registrant
14. Severity classification.
Moderate
15. Provide supplemental information here.
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
- Nervous and Muscular Systems
- Symptom - Muscle weakness
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
Unknown
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.)
1-26978487- The reporter indicates he and a friend may have been exposed to an insecticide containing the active ingredient permethrin. The reporter indicates an adult friend (Subform II, #1) of his used the product two weeks prior to his initial contact with the registrant. The reporter indicated this friend had been experiencing hallucinations and speaking in a 'ridiculous manner' following use of the product. The reporter did not describe the application or the onset of the symptoms seen. The reporter indicated he did not observe exposure but did observe the behavior. The reporter indicated he did personally (Subform II, #2) experience transitory muscle weakness while the previously described patient demonstrated the abnormal behavior. The reporter was advised the observed symptoms would not be expected following exposure to this product by any avenue. He was advised to seek medical assistance in determining the cause of the observed symptoms and if treatment is necessary. No further information is available
To be determined by Registrant
14. Severity classification.
Minor
