Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-6030

2. Registrant Information.

Registrant Reference Number: 3673600

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

Address: 202-6835 Century Ave

City: Mississauga

Prov / State: ON

Country: Canada

Postal Code: L5N 7K2

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

Human

4. Date registrant was first informed of the incident.

28-JUL-23

5. Location of incident.

Country: CANADA

Prov / State: NEW BRUNSWICK

6. Date incident was first observed.

28-JUL-23

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. 30472      PMRA Submission No.       EPA Registration No.

Product Name: ORTHO HOME DEF MX 5L WAND BBOY DU/40

• Active Ingredient(s)
  • PERMETHRIN

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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: Unknown / Inconnu

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?

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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Cardiovascular System
  • Symptom - Palpitations
  • Symptom - Other
  • Specify - Heart feels funny

4. How long did the symptoms last?

>30 min <=2 hrs / >30 min <=2 h

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?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

7/28/2023 Caller reports experiencing heart palpitations from an accidental dermal exposure to this product. Caller states he was using the product about 36-45 minutes ago when he got some of the mist on his face. About 20 minutes ago his symptoms started. Caller has rinsed the product off his skin, denies shortness of breath or chest pain, but states his heart feels funny. Caller is about 10-15 minutes away from his local emergency department. Caller is alone. Caller denied shortness of breath but could be heard taking short quick breaths on the phone. 7/31/2023 Attempted callback. Left a detailed message requesting a callback. Case and callback numbers provided. 8/1/2023 Attempted callback and spoke with caller. He went in and they put an echocardiogram machine on him. His heart rate was normal at 67 and there were no palpitations. They told him he could stay, but that he had no symptoms that warranted being seen. His symptoms lasted a total of 2 hrs. He has been asymptomatic since then. No further information is available.

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.