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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-5076
2. Registrant Information.
Registrant Reference Number: PROSAR Case # 1-27543561
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.
27-SEP-115. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
23-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. 22027 PMRA Submission No. EPA Registration No.
Product Name: Home Defense Max No-Pest Insecticidal 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: Res. - In Home / Rés. - à l'int. 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?
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: Female
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Rash
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?
No
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
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.
Respiratory
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
>24 hrs <=3 days / >24 h <=3 jours
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.)
1-27543561- The reporter indicates exposure of herself and a family member to an insecticidal product containing the active ingredient dichlorvos. The reporter indicated she had applied the product in her home four days prior to the initial contact with the registrant. She reporter both she (Subform II, #1) and her (age) grand son (Subform II, #2) had developed a rash on parts of their body (BSA was not described) four days after application. She did not describe a discreet exposure incident but indicates this is the only new item in the environment and indicates they may be breathing aromas from the product. The caller was advised exposure of the type described would not be expected to elicit the symptoms seen. She was advised to consult her physician to help determine the cause and appropriate treatment for her and her grandson¿s symptoms. She was also advised to remove the product from her home (this product in not labeled for use in the home). On follow up one week later the caller revealed her grand sons rash had spontaneously resolve but hers had not. She had been to two doctors. One had attributed her symptoms to a virus and the other poison ivy. The product had been removed from the home. 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: >1 <=6 yrs / > 1 < = 6 ans
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Rash
4. How long did the symptoms last?
>8 hrs <=24 hrs / > 8 h < = 24 h
5. Was medical treatment provided? Provide details in question 13.
Yes
6. a) Was the person hospitalized?
No
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
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.
Respiratory
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
>24 hrs <=3 days / >24 h <=3 jours
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.)
1-27543561- The reporter indicates exposure of herself and a family member to an insecticidal product containing the active ingredient dichlorvos. The reporter indicated she had applied the product in her home four days prior to the initial contact with the registrant. She reporter both she (Subform II, #1) and her (age) grand son (Subform II, #2) had developed a rash on parts of their body (BSA was not described) four days after application. She did not describe a discreet exposure incident but indicates this is the only new item in the environment and indicates they may be breathing aromas from the product. The caller was advised exposure of the type described would not be expected to elicit the symptoms seen. She was advised to consult her physician to help determine the cause and appropriate treatment for her and her grandson¿s symptoms. She was also advised to remove the product from her home (this product in not labeled for use in the home). On follow up one week later the caller revealed her grand sons rash had spontaneously resolve but hers had not. She had been to two doctors. One had attributed her symptoms to a virus and the other poison ivy. The product had been removed from the home. No further information is available.
To be determined by Registrant
14. Severity classification.
Minor
