Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-1462
2. Registrant Information.
Registrant Reference Number: PROSAR Case#:1-29626913
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.
30-MAR-12
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
25-MAR-12
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. 2009025
PMRA Submission No.
EPA Registration No.
Product Name: Scotts Turf Builder Lawn Fertilizer 10-0-0
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. - Out Home / Rés - à l'ext.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?
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
- Eye
- Symptom - Swollen eye
- Symptom - Discharge eye
- Symptom - Other
- Specify - pimples on eyelid/eyelid infection
- Symptom - Irritated eye
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.
Eye
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.)
1-29626913- The reporter indicates he was exposed to an herbicidal product containing the active ingredient Corn Gluten Meal. The reporter indicated he was applying the product five days prior at his residence when the wind blew the product in his eye. He reported he had rinsed his eye extensively after the exposure but the ocular irritation had ensued since the exposure. He had noted swelling and pimples on his eyelid at the point of his initial report. He indicated he was going to the doctor and had wanted literature to provide the physician as he had an appointment pending. On follow up four days later the patient was not reached but one of his coworkers was reached. The caller may have placed his initial report from his place of business. The coworker had indicated the patient had surgery on his eyelid the day of his initial report to drain his eyelid which was found to be infected. He indicated the patient was recovering. No further information was available. The symptoms described are inconsistent with the expectations of the active ingredient or the finished product.
To be determined by Registrant
14. Severity classification.
Major
15. Provide supplemental information here.