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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-5075
2. Registrant Information.
Registrant Reference Number: PROSAR Case# 1-27552863
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
Packaging Failure
4. Date registrant was first informed of the incident.
27-SEP-115. Location of incident.
Country: CANADA
Prov / State: BRITISH COLUMBIA
6. Date incident was first observed.
27-SEP-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?
No
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
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 - Headache
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)
Pesticide Spill
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
None
10. Route(s) of exposure.
Skin
Respiratory
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
<=30 min / <=30 min
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.)
1-27552863- The reporter indicated he had been exposed to an insecticide containing the active ingredient permethrin. The reporter, an adult male, stated he had been shopping earlier the day of his initial contact with the registrant. He stated he picked the product up from the store shelf and found it had been cracked. He had gotten the product on his hand and without thinking he scratched an itch adjacent to his nose. He reports he did not wash his hands until he got home some time later. He reports dermal and potential inhalation exposure, the caller stated he had a headache. The caller was advised of proper decontamination, of the parasthesia sensations that can be encountered following dermal exposure to a pyrethroid, and how to mitigate that sensation. He was advised the non-specific symptom of headache may be encountered if the caller found the aroma associated with the product offensive. He was advised no harm would be expected from the exposure described and the threshold at which he might seek medical attention. No further information is available.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
Subform VI: Packaging Failure
1. What is the type of packaging that failed?
Jug-plastic / Cruche-plastique
2. Did packaging failure occur during?
Storage
3. Did packaging failure result in?
potential exposure
4. Describe how the packaging failed and the surrounding circumstances, including a description of the potential injury or exposure.
1-27552863- The reporter indicated he had been exposed to an insecticide containing the active ingredient permethrin. The reporter, an adult male, stated he had been shopping earlier the day of his initial contact with the registrant. He stated he picked the product up from the store shelf and found it had been cracked. He had gotten the product on his hand and without thinking he scratched an itch adjacent to his nose. He reports he did not wash his hands until he got home some time later. He reports dermal and potential inhalation exposure, the caller stated he had a headache. The caller was advised of proper decontamination, of the parasthesia sensations that can be encountered following dermal exposure to a pyrethroid, and how to mitigate that sensation. He was advised the non-specific symptom of headache may be encountered if the caller found the aroma associated with the product offensive. He was advised no harm would be expected from the exposure described and the threshold at which he might seek medical attention. No further information is available.
