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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-2855

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-37004868

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. 9167      PMRA Submission No.       EPA Registration No.

Product Name: Home Defense Max Ant Eliminator Liquid

• Active Ingredient(s)
  • BORAX

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

• Respiratory System
  • Symptom - Irritated nose

• Skin
  • Symptom - Red 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)

Contact with treated area

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.

Unknown

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.)

1-37004868 - The reporter, a home owner, indicated that she was exposed to an insecticide containing the active ingredient borax. The reporter states that she applied 3-4 drops of this product on a piece of aluminum foil and placed it in her kitchen pantry. The ants walked on the product and then walked all over the reporters plates, utensils and other pantry items. The reporter indicated that shortly after product application she developed nasal irritation and her face has been a little red. The reporter was advised that contact with the product may cause transient irritation by all routes and per package labeling contamination of food and eating utensils should be avoided. Removal of the product and clean-up of the pantry was recommended. No further information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.