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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-3381
2. Registrant Information.
Registrant Reference Number: PROSAR case #: 1-30876334
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.
16-JUL-125. Location of incident.
Country: CANADA
Prov / State: ONTARIO
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. 27201 PMRA Submission No. EPA Registration No.
Product Name: Ortho Ant B Gon Max Ant
- Active Ingredient(s)
- PERMETHRIN
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: Unknown / Inconnu
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: >64 yrs / > 64 ans
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Hives
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)
Application
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
Chemical resistant gloves
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.)
1-30876334 - The reporter, the spouse of the patient, indicated that her husband may have been exposed to an insecticidal product containing the active ingredient permethrin. The reporter indicated that her husband applied this product while wearing gloves, shorts and a short sleeved shirt one day prior to initial contact. The patient does not remember getting the product on his skin or inhaling the product but shortly after applying the product he developed non-itchy hives on his face, torso and legs. Nine days prior to initial contact the patient had heart surgery for stent placement. The patient has been on medications since that time but the patients pharmacist does not believe that these medications would cause hives. The patient does have known allergies to dust and takes Flonase. The reporter was advised that there are several possible causes of hives including sensitivities to medications or environmental agents. It was recommended that the patient discontinue use of the product if it is suspected to be the cause for the reaction and to seek medical attention for the worsening hives. On callback 4 days later the patient indicated that he went to the doctor where he was given topical cortisone cream and his symptoms are improving. The underlying cause for his reaction had not yet been identified. No further information is available.
To be determined by Registrant
14. Severity classification.
Minor
