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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-4560
2. Registrant Information.
Registrant Reference Number: PROSAR Case#: 1-27050224
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.
04-AUG-115. Location of incident.
Country: UNITED STATES
Prov / State: DELAWARE
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.
Active(s)PMRA Registration No. PMRA Submission No. EPA Registration No. Unknown
Product Name: Weed-B-Gon (non-specific)
- Active Ingredient(s)
- 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)
- Unknown
- DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, OR SODIUM SALT)
- Unknown
- MECOPROP-P (PRESENT AS AMINE SALT)
- Unknown
- 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)
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
Préciser le type: lawn
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
- Renal System
- Symptom - Other
- Specify - "Decreased kidney function"
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Yes
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.
Skin
11. What was the length of exposure?
>15 min <=2 hrs / >15 min <=2 h
12. Time between exposure and onset of symptoms.
>1 mo <=2 mos / > 1 mois < = 2 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.)
1-27050224- The reporter indicated he had been exposed to n herbicide containing the active ingredients 2,4D, dicamba and, mecoprop-p. The reporter indicated he had applied the product to his residential lawn approximately two months ago but did not have a precise date in mind. The reporter indicated he had gotten the product on his arms and legs and did not rinse the product off of his skin for at least one hour following the exposure. He reports recently he has seen his doctor and 'blood work' has revealed 'decreasing kidney function'. The caller was unable to be more specific about the blood work or the kidney function changes observed. The reporter was advised of the potential for dermal irritation following skin contact with the product. He was advised that symptom may be mitigated by flushing the skin with water. He was advised the systemic abnormalities seen would not be expected following skin contact. The time line further conveyed inconsistency. No further information is available.
To be determined by Registrant
14. Severity classification.
Major
