Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2016-4679
2. Registrant Information.
Registrant Reference Number: ProPharma Group case #: 1-44734219
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.
05-JUL-16
5. Location of incident.
Country: CANADA
Prov / State: NOVA SCOTIA
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. 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?
Yes
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Res. - In Home / Rés. - à l'int. 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: Female
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Rash
- Symptom - Red skin
- Symptom - Pruritus
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)
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.
Skin
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.)
1-44734219 - The reporter indicated she may have been exposed to an insecticide containing the active ingredient permethrin. On the day of initial contact with the registrant, the reporter stated she had used the product inside her house an unknown number of days before. She stated she now had an itchy, red, rash on a few places on her body. The reporter was told this was not an expected reaction to routine product use and to seek medical attention should the symptoms continue. On follow-up call two days later, the reporter stated she had seen the doctor who prescribed medications. The doctor stated he didnt think the symptoms were related to the product. No additional information is available.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.