Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-3900

2. Registrant Information.

Registrant Reference Number: 3598167

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.

11-MAY-23

5. Location of incident.

Country: CANADA

Prov / State: MANITOBA

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. 23372      PMRA Submission No.       EPA Registration No.

Product Name: ORTHO ANT B GON MAX ANT TRAPS 10CT/8

• Active Ingredient(s)
  • BORAX

---

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

• Cardiovascular System
  • Symptom - Chest pain

• General
  • Symptom - Drowsiness

• Nervous and Muscular Systems
  • Symptom - Headache

• Respiratory System
  • Symptom - Nose bleed
  • Symptom - Shortness of breath
  • Symptom - Difficulty Breathing
  • Specify - Can barely breathe

• General
  • Symptom - Other
  • Specify - Feels like he cant wake up

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)

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

Other

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.

Unknown

11. What was the length of exposure?

>1 wk <=1 mo / > 1 sem < = 1 mois

12. Time between exposure and onset of symptoms.

>1 wk <=1 mo / > 1 sem < = 1 mois

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.)

5/11/2023 Caller states the traps were in his living room vents. He states his mother placed them in his vents a couple of weeks ago. The last few days he has been having headaches, can barely breathe, nose bleeds, chest is hurting, and sometimes feels like he can't wake up. Caller says when he left the home his symptoms went away and he felt better. 5/12/2023 Attempted call back. No answer. Left message with reason for call, and case and callback numbers. 5/15/2023 Attempted call back. No answer. Left message with reason for call, and case and callback numbers.

To be determined by Registrant

14. Severity classification.

Moderate

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.