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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2022-0914

2. Registrant Information.

Registrant Reference Number: ProPharma Group case #: 2021SCCA00034269

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.

5. Location of incident.

Country: CANADA

Prov / State: NEW BRUNSWICK

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.

PMRA Registration No. 27201      PMRA Submission No.       EPA Registration No. Unknown

Product Name: ORTHO ANT B GON MAX ANT ELIMINATOR WITH WAND APPLICATOR

• Active Ingredient(s)
  • PERMETHRIN

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: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Nausea

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

Contact with treated area

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.

Respiratory

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.)

2021SCCA00034269 - The reporter indicates an exposure to a pesticide containing the active ingredient permethrin. Approximately three months before the day of initial contact, the reporter applied the pesticide to a single room in their home. The reporter stated since application, they develop nausea every time they re-enter the room. The reporter was advised to clean the affected room and seek medical attention should the symptom persist. No additional information is available.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

Please note that this submission in no way implies that Scotts Canada Ltd. agrees with the allegations contained within this incident report.