Déclaration d'incident

Sous-formulaire I: Renseignements généraux

1.Type de rapport.

Nouvelle déclaration d'incident

No de la demande: 2022-6475

2. Renseignements concernant le titulaire.

Numéro de référence du titulaire d'homologation: 3430019

Nom du titulaire (nom légal complet, aucune abbréviation): Scotts Canada Ltd.

Adresse: 2000 Argentia Road - Plaza 2 Suite 300

Ville: Mississauga

État: ON

Pays: Canada

Code postal /Zip: L5N1V8

3.Choisir le (les) sous-formulaire(s) correspondant à l'incident.

Incident chez l'humain

Défaillance de l'emballage

4. Date à laquelle le titulaire d'homologation a été informé pour la première fois de l'incident.

07-NOV-22

5. Lieu de l'incident.

Pays: UNITED STATES

État: INDIANA

6. Date de la première observation de l'incident.

Inconnu

Description du produit

7. a) Donner le nom de la matière active et, si disponibles, le numéro d'homologation et le nom du produit (incluant tous les mélanges). Si le produit n'est pas homologué, donner le numéro de la demande d'homologation.

Matière(s) active(s)

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ARLA No d'homologation       ARLA No de la demande d'homologation       EPA No d'homologation. 73327-18

Nom du produit: ACE WEED & GRASS KILLER CONCENTRATE2

• Matière active
  • DICAMBA (PRESENT AS ACID, AMINE SALT, ESTER, OR SODIUM SALT)
    • Inconnu
  • DIQUAT
    • Inconnu
  • FLUAZIFOP-P-BUTYL
    • Inconnu

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7. b) Type de formulation.

Liquide

Renseignments sur l'application

8. Est-ce que le produit a été appliqué?

Oui

9. Dose d'application.

Inconnu

10. Site d'application (choisir tout ce qui s'applique).

Site: Res. - Out Home / Rés - à l'ext.maison

11. Donner tout renseignement additionnel concernant l'application (comment le produit a été appliqué, la quantité utilisée, la superficie de la zone traitée, etc.)

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

À être déterminé par le titulaire

12. Selon vous, le produit a-t-il été utilisé en conformité avec le mode d'emploi de L'étiquette?

Oui

Sous-formulaire II : Incident chez l'humain (Obligation d'utiliser un formulaire séparé pour chaque personne affectée)

1. Source de la déclaration.

Personne affectée

2. Renseignement démographique sur la personne affectée

Sexe: Homme

Âge: >64 yrs / > 64 ans

3. Énumérez tous les symptômes, au moyen des choix suivants.

Système

• Systèmes nerveux et musculaire
  • Symptôme - Insomnie
  • Symptôme - Engourdissement

• Peau
  • Symptôme - Irritation de la peau
  • Symptôme - Éruption cutanée
  • Symptôme - Autre
  • Specify - Skin warm
  • Symptôme - Autre
  • Specify - Shingles

• Système gastro-intestinal
  • Symptôme - Vomit

• General
  • Symptôme - Fièvre
  • Symptôme - Douleur
  • Symptôme - Autre
  • Specify - Cannot bend fingers sideways

• Peau
  • Symptôme - Autre
  • Specify - Hot sensation on right hand

4. Quelle a été la durée des symptômes?

Unknown / Inconnu

5. La personne affectée a-t-elle reçu des soins médicaux? Donner les détails à la question 13.

Oui

6. a) Est-ce que la personne a été hospitalisée?

Oui

6. b) Pendant combien de temps?

1

Day(s) / Jour(s)

7. Scénario d'exposition

Non professionnel

8. Comment l'exposition s'est-elle produite? (cocher tout ce qui s'applique)

Application

Quelle était l'activité? Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding the activity

Déversement de pesticide

9.Si l'exposition s'est produite lors du traitement ou au moment du retour dans la zone traitée, de l'équipement de protection individuelle était-il porté? (cocher tout ce qui s'applique)

Aucun

10. Voie(s) d'exposition.

Peau

11.Durée de l'exposition?

Unknown / Inconnu

12.Temps écoulé entre l'exposition et l'apparition des symptômes.

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

13.Donner tout détail additionnel au sujet de l'incident (p.ex. description des symptômes tels que la fréquence et la gravité, type de soins médicaux, résultats des tests médicaux, quantité de pesticide à laquelle la personne a été exposée, etc.)

11/7/2022 Around mid-August 2022 the consumer was spraying the diluted product when the line fell off the sprayer, causing it to spray product onto his hand and wrist. He briefly rinsed exposed skin an unspecified amount of time later and remained asymptomatic initially after doing so. On September 1st, 2022 he began experiencing pain in his wrist, and several days later developed a rash on his wrist and arm. He was diagnosed with shingles and prescribed Valtrex by his doctor an unspecified period of time later. The Valtrex helped with the pain radiating up his arm, but did not help with pain present in his palm. He has since developed difficulty sleeping due to the pain, and his pinky finger on the affected hand is now numb. His doctor additionally prescribed Lyrica and Gabapentin, but the pain has intensified and the only thing that helps is putting his hand on ice. He was started on a second course of Valtrex by his primary care doctor on November 3rd, 2022 and given a list of neurologists so he could schedule an electromyography. He additionally began seeing an orthopedist who advised they had never seen effects like his caused by shingles, but did not believe the symptoms were caused by the product, either. 11/11/22 Follow up with the consumer revealed no improvement in symptoms, and he now reports his ring finger is also numb and he cannot bend his fingers sideways. He additionally has a hot sensation on his right hand. He has also added Salonpas and Naproxen to his course of treatments. He has scheduled an electromyography for November 18th, 2022. 11/21/22 Additional follow up revealed that the consumer completed his electromyography on November 18th, 2022 but needed to schedule another visit to go over results. 12/7/22 Additional follow up revealed the consumer received results from his electromyography on December 2nd, 2022 and was told again by the physician they felt his effects were due to shingles. He was prescribed another course of Valtrex and Gabapentin. 12/7/22 Additional follow up from the consumer was received. He noted that he forgot to mention going to the emergency room on December 4th, 2022 for vomiting and a fever. He was admitted to overnight and given one bag of intravenous fluids, Zofran, and Tylenol. He additionally underwent two electrocardiograms, unknown bloodwork, and had a computerized tomography scan of his abdomen, all of which were within normal limits and unremarkable. The doctors did not know the cause of his symptoms and he was discharged on December 5th, 2022 with Zofran and a diagnosis of vomiting of unknown origin. No further information is available at this time.

À être déterminé par le titulaire

14. Classification selon la gravité.

Majeure

15. Donner des renseignements additionnels ici.

Sous-formulaire VI : Défaillance de l'emballage

1. Type d'emballage défaillant?

Spray Bottle / Flacon pulvérisateur

2. La défaillance de l'emballage est apparue pendant?

L'utilisation du produit

3. La défaillance de l'emballage a donné lieu à :

une blessure potentielle

une exposition potentielle

4.Décrire pourquoi l'emballage a été défaillant et dans quelles circonstances, décrire notamment la blessure ou l'exposition potentielle.

11/7/2022 Around mid-August 2022 the consumer was spraying the diluted product when the line fell off the sprayer, causing it to spray product onto his hand and wrist. He briefly rinsed exposed skin an unspecified amount of time later and remained asymptomatic initially after doing so. On September 1st, 2022 he began experiencing pain in his wrist, and several days later developed a rash on his wrist and arm. He was diagnosed with shingles and prescribed Valtrex by his doctor an unspecified period of time later. The Valtrex helped with the pain radiating up his arm, but did not help with pain present in his palm. He has since developed difficulty sleeping due to the pain, and his pinky finger on the affected hand is now numb. His doctor additionally prescribed Lyrica and Gabapentin, but the pain has intensified and the only thing that helps is putting his hand on ice. He was started on a second course of Valtrex by his primary care doctor on November 3rd, 2022 and given a list of neurologists so he could schedule an electromyography. He additionally began seeing an orthopedist who advised they had never seen effects like his caused by shingles, but did not believe the symptoms were caused by the product, either. 11/11/22 Follow up with the consumer revealed no improvement in symptoms, and he now reports his ring finger is also numb and he cannot bend his fingers sideways. He additionally has a hot sensation on his right hand. He has also added Salonpas and Naproxen to his course of treatments. He has scheduled an electromyography for November 18th, 2022. 11/21/22 Additional follow up revealed that the consumer completed his electromyography on November 18th, 2022 but needed to schedule another visit to go over results. 12/7/22 Additional follow up revealed the consumer received results from his electromyography on December 2nd, 2022 and was told again by the physician they felt his effects were due to shingles. He was prescribed another course of Valtrex and Gabapentin. 12/7/22 Additional follow up from the consumer was received. He noted that he forgot to mention going to the emergency room on December 4th, 2022 for vomiting and a fever. He was admitted to overnight and given one bag of intravenous fluids, Zofran, and Tylenol. He additionally underwent two electrocardiograms, unknown bloodwork, and had a computerized tomography scan of his abdomen, all of which were within normal limits and unremarkable. The doctors did not know the cause of his symptoms and he was discharged on December 5th, 2022 with Zofran and a diagnosis of vomiting of unknown origin. No further information is available at this time.

À l'usage du titulaire seulement

5. Donner des renseignements additionnels ici.