Print | Need Larger Text?

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-2874

2. Registrant Information.

Registrant Reference Number: PROSAR Case#:1-30513189

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.

5. 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.

PMRA Registration No. 30144      PMRA Submission No.       EPA Registration No.

Product Name: Ecosense Weed Be Gon Select Herbicide Concentrate

• Active Ingredient(s)
  • IRON (PRESENT AS FEHEDTA)

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

• Skin
  • Symptom - Irritated skin
  • Symptom - Pruritus
  • Symptom - Erythema
  • Symptom - Rash

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)

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?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>3 days <=1 wk / >3 jours <=1 sem

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.)

1-30513189- The reporter indicates he was exposed to an herbicidal product containing the active ingredient Iron HEDTA. The reporter indicated he had gotten the diluted solution of the product on his skin two weeks prior to his initial contact with the registrant. He reports contact with his hands, stomach and chest. He reported he showered the evening of his exposure. He reported he developed a rash on his chest three days later. He also described erythema and rash in that location. The caller reports he had spoken to a pharmacist about his symptoms and was provided over the counter medications which had not helped. The caller was advised follow up with his doctor. The symptoms seen would not be anticipated following the exposure described. The reporter did not respond to follow up attempts. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.