Print | Need Larger Text?

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-3959

2. Registrant Information.

Registrant Reference Number: PROSAR Case#: 1-33955530

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: 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.

PMRA Registration No. 29695      PMRA Submission No.       EPA Registration No.

Product Name: Ecosense Weed B Gon RTU Weed Control

• 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.

Medical Professional

2. Demographic information of data subject

Sex: Male

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Headache

• General
  • Symptom - Fatigue
  • Symptom - Chills
  • Symptom - Malaise
  • Symptom - Sweating

• Blood
  • Symptom - Thrombocytopenia
  • Symptom - Leukopenia

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?

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.

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>1 mo <=2 mos / > 1 mois < = 2 mois

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.)

1-33955530 - The reporter, a physician, indicated that her patient may have been exposed to an herbicide containing the active ingredient Ferric HEDTA. The physician reported that a (age) year-old, male patient who was recently diagnosed with leukopenia and thrombocytopenia used four large containers of this product approximately one month prior to initial contact with the registrant. No exposure or direct contact with the product was noted during application but the reporter did state that the patient was quite close to the product. Shortly after product use the patient suffered from general malaise, chills, sweats, headaches and fatigue. The reporter was advised that the product has a wide margin of safety and that the described symptoms are not consistent with the described exposure. Further diagnostics were recommended to identify the cause for the patients illness. No further information is available.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.