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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2016-3117
2. Registrant Information.
Registrant Reference Number: 191649
Registrant Name (Full Legal Name no abbreviations): Arch Chemicals
Address: 1200 Bluegrass Lakes Pkwy
City: Alpharetta
Prov / State: Georgia
Country: U.S.A.
Postal Code: 30004
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
26-MAY-16
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
26-MAY-16
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. 23324
PMRA Submission No.
EPA Registration No. 1258-1173
Product Name: HTH Extra Super Shock
- Active Ingredient(s)
- AVAILABLE CHLORINE, PRESENT AS CALCIUM HYPOCHLORITE
7. b) Type of formulation.
Application Information
8. Product was applied?
Unknown
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
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.
Other
2. Demographic information of data subject
Sex: Female
Age: >6 <=12 yrs / > 6 < = 12 ans
3. List all symptoms, using the selections below.
System
- Eye
- Symptom - Foreign body sensation in eye
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)
Other
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.
Eye
11. What was the length of exposure?
<=15 min / <=15 min
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.)
Caller's daughter got product in her eyes as they were adding to their swimming pool. They had rinsed her eyes for about an hour prior to the notification, but the girl was complaining that she felt like something was in her eye. Recommended further medical treatment.
To be determined by Registrant
14. Severity classification.
Moderate
15. Provide supplemental information here.