Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2016-3335
2. Registrant Information.
Registrant Reference Number: ProPharma Group case #: 1-44205171
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.
23-MAY-16
5. Location of incident.
Country: CANADA
Prov / State: SASKATCHEWAN
6. Date incident was first observed.
22-MAY-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. 27521
PMRA Submission No.
EPA Registration No.
Product Name: ORTHO HOME DEFENSE MAX PERIMETER & INDOOR INSECT CONTROL READY-TO-USE
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: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
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)
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.)
1-44205171 - The reporter indicated her husband was exposed to an herbicide containing the active ingredient permethrin. The reporter said her husband used the product one day before initial contact with the registrant, then felt dizzy before going to bed that night. On the day of initial contact with the registrant, the reporter stated her husband still felt dizzy. The reporter stated she did not know if her husband had inhaled any of the product fumes. The reporter was advised to have her husband get fresh air as well as shower and seek medical attention if the symptoms do not subside. Due to the persistence of the symptoms, it is possible they are not related to product exposure. No follow-up was attempted. No additional information is available.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.