Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2016-2285
2. Registrant Information.
Registrant Reference Number: ProPharma case #: 1-43610394
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.
27-MAR-16
5. Location of incident.
Country: CANADA
Prov / State: UNKNOWN
6. Date incident was first observed.
27-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. 28404
PMRA Submission No.
EPA Registration No.
Product Name: SCOTTS ECOSENSE BUG-B-GON INSECTICIDE CONCENTRATE
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.
Data Subject
2. Demographic information of data subject
Sex: Male
Age: >19 <=64 yrs / >19 <=64 ans
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
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.
Oral
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.)
1-43610394 - The reporter indicated he was exposed to an insecticidal spray containing the active ingredient pyrethrins. The reporter was spraying the diluted product about an hour before contact with the registrant. The reporter temporarily put the spraying hose in his mouth, got a taste of the product and at the time of the call indicated that he was feeling nauseous. The reporter was advised that small ingestions may cause transient GI upset. No further information is available.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.