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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-5280

2. Registrant Information.

Registrant Reference Number: PROSAR case #: 1-31683324

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. 22027      PMRA Submission No.       EPA Registration No.

Product Name: Home Defense Max No Pest Insecticide Strip (Ortho) 2

• Active Ingredient(s)
  • DICHLORVOS PLUS RELATED ACTIVE COMPOUNDS

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. - In Home / Rés. - à l'int. 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: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Pain
  • Symptom - Burning skin

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.

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.)

1-31683324 - The reporter indicated that she was exposed to an insecticidal product containing the active ingredient dichlorvos. The reporter an adult female indicated that she had applied the product to the interior of her home for some unspecified amount of time and recently, within the past week, she notes a burning sensation on the skin of her extremities when she contacts her furniture. The reporter was advised that the described symptoms are not consistent with product exposure and it was recommended that she seek medical advice. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.