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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-4561
2. Registrant Information.
Registrant Reference Number: PROSAR Case #: 1-27065270
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.
06-AUG-115. Location of incident.
Country: CANADA
Prov / State: QUEBEC
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. 22027 PMRA Submission No. EPA Registration No.
Product Name: Ortho Home Defense Max No-Pest Insecticide Strip
- Active Ingredient(s)
- DICHLORVOS PLUS RELATED ACTIVE COMPOUNDS
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: Pub. Area - Indoor/Zone publique - int
Préciser le type: restaurant
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.
Data Subject
2. Demographic information of data subject
Sex: Unknown
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
- Symptom - Headache
- General
- Symptom - Fatigue
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
Occupational
8. How did exposure occur? (Select all that apply)
Contact with treated area
What was the activity? restaurant employee (application area is various sites within the restaurant)
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.)
1-27065270- The reporter indicated he and an unknown number of co-workers may have been exposed to an insecticidal product containing the active ingredient dichlorvos. The reporter indicated he was a restaurant employee where the product was used in several locations which included near the cash register, the rest room, and another employee common room. He indicated he and several other employees at the restaurant had complained of symptoms of headache and tiredness. He did not describe the number of other employees involved, the avenue of exposure, when the product was applied, or when the symptoms developed with respect to when the product was either applied or exposure had taken place. The caller had not obtained treatment advice at the point of the call. The caller was advised to seek medical care for the symptoms described. The use described was against label recommendations, no further information is available.
To be determined by Registrant
14. Severity classification.
Minor
