Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-2945
2. Registrant Information.
Registrant Reference Number: ProPharma Group case #: 1-48015763
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.
29-APR-17
5. Location of incident.
Country: CANADA
Prov / State: BRITISH COLUMBIA
6. Date incident was first observed.
28-APR-17
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. 27801
PMRA Submission No.
EPA Registration No.
Product Name: ORTHO KILLEX LAWN WEED CONTROL CONCENTRATE
- Active Ingredient(s)
- 2,4-D (PRESENT AS AMINE SALTS : DIMETHYLAMINE SALT, DIETHANOLAMINE SALT, OR OTHER AMINE SALTS)
- DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, OR SODIUM SALT)
- MECOPROP-P (PRESENT AS DIMETHYLAMINE SALT)
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
- 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)
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
Respiratory
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.)
1-48015763 - The reporter, a home owner, indicates he was exposed to a pesticide containing the active ingredients dicamba (present as acid, amine salt, ester, or sodium salt), 2,4-D (present as amine salts: dimethylamine salt, diethanolamine salt, or other amine salts), and mecoprop-p (present as dimethylamine salt). One day before the day of initial contact with the registrant, the reporter indicated he applied the diluted product to his lawn and developed a tingling sensation around his mouth and dizziness soon after application. On the day of initial contact with the registrant, the reporter stated the tingling sensation still persisted. The reporter was advised that the product might cause minor skin irritation, but if the symptoms lasted past 24 hours, medical evaluation should be sought. No follow-up was attempted. No additional information is available.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.