Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-4699
2. Registrant Information.
Registrant Reference Number: PROSAR case #: 1-31645815
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.
Domestic Animal
4. Date registrant was first informed of the incident.
27-SEP-12
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
27-SEP-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. 28258
PMRA Submission No.
EPA Registration No.
Product Name: Home Defense Max Perimeter/Indoor Insect Control with Pull N Spray App
7. b) Type of formulation.
Application Information
8. Product was applied?
Unknown
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 III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Siberian Husky
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
1.2
7. Weight (provide a range if necessary )
63.8
lbs
8. Route(s) of exposure
Oral
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
<=30 min / <=30 min
11. List all symptoms
System
12. How long did the symptoms last?
Unknown / Inconnu
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Unknown/Inconnu
16. How was the animal exposed?
Accidental ingestion/Ingestion accident.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1-31645815 - The reporter, a pet owner, indicated that his dog was exposed to an insecticidal product containing the active ingredient permethrin. The pet owner reported that approximately 5 minutes prior to initial contact with the registrant the product dripped on the floor and his 1-year-old, 63.8 pound, female, Siberian husky licked the drip of the floor and now the dog is drooling. Caller was advised that transient drooling and GI upset may result because of the product's unpleasant taste but no further symptoms would be expected. No further information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here