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: 2015-1434
2. Registrant Information.
Registrant Reference Number: PROSAR case #: 1-40015367
Registrant Name (Full Legal Name no abbreviations): Scotts Canada Ltd.
Address: 2000 Argentia Road, Plaza 2, Suite 300
City: Mississauga
Prov / State: Ontario
Country: Canada
Postal Code: L5N1V8
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
21-MAR-155. Location of incident.
Country: CANADA
Prov / State: QUEBEC
6. Date incident was first observed.
21-MAR-15Product 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. 9167 PMRA Submission No. EPA Registration No.
Product Name: Ant-B-Gon Max Ant Killer Liquid (Ortho)
- Active Ingredient(s)
- BORAX
7. b) Type of formulation.
Application Information
8. Product was applied?
Unknown
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.
Other
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 - Numbness
- Specify - mouth was feeling numb
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? eating from a plate that had some product residue on it.
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.
Oral
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
<=30 min / <=30 min
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.)
1-40015367 - The reporter indicated that his wife was exposed to an insecticide containing the active ingredient borax. The reporter stated that just prior to his initial call his wife ate from a plate that had some product residue on it and at the time of the initial call her mouth was feeling numb. The reporter was advised that the product has a wide margin of safety but with ingestion transient gastrointestinal irritation is possible. The reporter could not be reached on routine follow-up attempts. No additional information is available.
To be determined by Registrant
14. Severity classification.
Minor
