Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2016-2284
2. Registrant Information.
Registrant Reference Number: ProPharma case #: 1-43508859
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.
16-MAR-16
5. Location of incident.
Country: CANADA
Prov / State: BRITISH COLUMBIA
6. Date incident was first observed.
16-MAR-16
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.
Active(s)
PMRA Registration No. 31645
PMRA Submission No.
EPA Registration No.
Product Name: SCOTTS 2 IN 1 MOSS CONTROL READY-TO-SPRAY FOR LAWNS AND HARD SURFACES
- Active Ingredient(s)
- POTASSIUM SALTS OF FATTY ACIDS
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.
Data Subject
2. Demographic information of data subject
Sex: Female
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
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
Unknown
8. How did exposure occur? (Select all that apply)
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.
Eye
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.)
1-43508859 - The reporter indicated she had been exposed to an herbicide containing the active ingredient potassium salts of fatty acids. The reporter accidentally got some of the product in her eyes and mouth thirty minutes prior to her initial call and at the time of the call she was complaining that her eye was irritated. Reporter was advised that the product may cause transient ocular irritation and flushing of the eye was recommended. Medical attention was advised for any severe or persistent symptoms. No further information is available.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.