Health Canada
www.hc-sc.gc.ca
Common menu bar links
Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2014-2063
2. Registrant Information.
Registrant Reference Number: PROSAR case: 1-37219487
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-MAY-145. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
10-MAY-14Product 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. 27521 PMRA Submission No. EPA Registration No.
Product Name: Home Defense Max Perimeter and Indoor Insect Control RTU
- 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: 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: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
- Symptom - Fainting
- Symptom - Headache
- Respiratory System
- Symptom - Shortness of breath
- Symptom - Other
- Specify - Respiratory arrest
4. How long did the symptoms last?
>3 days <=1 wk / >3 jours <=1 sem
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)
Contact with treated area
Amount of time between application and contact 0
Hour(s) / Heure(s)
What was the activity? Daily living
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.
Respiratory
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.)
1-37219487 - The reporter indicated that she was exposed to an insecticide containing the active ingredient permethrin. The reporters landlord applied the insecticide in the reporters apartment two weeks prior to initial contact with the registrant. The reporter was in her apartment during product application. That evening the reporter developed a headache. The next day she was out of her apartment, riding in a car with a friend, and she started having trouble breathing. She got out of the car and fainted on the sidewalk. A passerby picked her up and ran her to a nearby hospital. Per the reporter she stopped breathing and was put on oxygen. She was unconscious for 4 hours. She was sent home later that day and for the next 6 days she was incoherent. The reporter indicates that she does have asthma. The reporter was advised that transient headache and transient respiratory irritation can be seen when inhaling the fumes. But, other than the headache, the described symptoms and the time frame in which they developed are not consistent with exposure to the product. No further information is available.
To be determined by Registrant
14. Severity classification.
Major
