Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-4708

2. Registrant Information.

Registrant Reference Number: PROSAR case #: 1-31636717

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.

26-SEP-12

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

26-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)

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PMRA Registration No. 30072      PMRA Submission No.       EPA Registration No.

Product Name: Ecosense Moss B Gon Herbicidal Soap Moss Algae Killer RTU

• Active Ingredient(s)
  • AMMONIUM SALT OF FATTY ACID

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7. b) Type of formulation.

Application Information

8. Product was applied?

No

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 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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Pain

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)

Other

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.

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.)

1-31636717 - The reporter indicated that he was exposed to an herbicide containing the active ingredient ammonium soaps of higher fatty acids. The reporter an elderly adult male indicated that approximately two hours prior to initial contact with the registrant he had picked up the bottle at a store and some of the product spilled on his hands. The reporter washed his hands with soap for over 10 minutes after the exposure. At the time of initial contact the reporter indicated that his elbow was hurting. The reporter was advised that the product may cause transient dermal irritation at the site of contact but elbow pain is not consistent with product exposure. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.