Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-2294

2. Registrant Information.

Registrant Reference Number: 3483428

Registrant Name (Full Legal Name no abbreviations): Scotts Canada Ltd.

Address: 2000 Argentia Road - Plaza 2 Suite 300

City: Mississauga

Prov / State: ON

Country: Canada

Postal Code: L5N1V8

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

02-JAN-23

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

30-DEC-22

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)

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PMRA Registration No. 31500      PMRA Submission No.       EPA Registration No.

Product Name: TOMCAT MOUSE KLR RFLLBL T1 /8 BAIT/4 BAG

• Active Ingredient(s)
  • DIPHACINONE (PRESENT IN FREE FORM OR AS SODIUM SALT)

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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).

Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding application.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Yes

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

• Nervous and Muscular Systems
  • Symptom - Headache

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Application

What was the activity? Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding the activity

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

None

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

<=15 min / <=15 min

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.)

1/2/2023 The caller is reporting that he has been experiencing nausea and a headache after placing the product within his home 3 days ago. The caller advised that he was feeling bad before he placed the product within his home and he was not sure if the product could have caused the symptoms that he is experiencing. The caller stated that he placed the bait within the station without gloves on, but he did wash his hands with water afterwards for an undisclosed amount of time. He advised that he was feeling a little better but within 24 hours of placing the product, the symptoms returned.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews.