Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2016-2647
2. Registrant Information.
Registrant Reference Number: ProPharma Group case #: 1-43823874
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.
18-APR-16
5. Location of incident.
Country: CANADA
Prov / State: BRITISH COLUMBIA
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.
Active(s)
PMRA Registration No. 4282
PMRA Submission No.
EPA Registration No.
Product Name: (GREEN CROSS) MALATHION 500 EC LIQUID INSECTICIDE
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: Male
Age: >64 yrs / > 64 ans
3. List all symptoms, using the selections below.
System
- General
- Symptom - Pain
- Specify - Throat pain
- Symptom - Pain
- Specify - Neck pain
4. How long did the symptoms last?
Unknown / Inconnu
5. Was medical treatment provided? Provide details in question 13.
Yes
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)
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.)
1-43823874 - The reporter indicated her father was exposed to an insecticide containing the active ingredient malathion. The reporter said her (age) year-old father was exposed to the product when a friend found an old bottle of the product and placed some behind the fathers refrigerator on an unknown date. On the day of contact with the registrant, the reporter said her father was experiencing neck, throat, and chest pain. When the reporter called, she was on the way to the hospital with her father. On follow-up call the day after initial contact with the registrant, the reporter indicated her father had seen his doctor who had increased his water pill. The father is staying with the reporter until his home is vented. No additional information is available.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.