Health Canada
Symbol of the Government of Canada
Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-8953

2. Registrant Information.

Registrant Reference Number: 1826900

Registrant Name (Full Legal Name no abbreviations): BioLab Inc., A Chemtura Company

Address: 1005 Copperstone Drive

City: Pickering

Prov / State: ON

Country: Canada

Postal Code: L1W 4A5

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

Human

4. Date registrant was first informed of the incident.

05-NOV-07

5. Location of incident.

Country: UNITED STATES

Prov / State: PENNSYLVANIA

6. Date incident was first observed.

03-NOV-07

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. 27311      PMRA Submission No.       EPA Registration No. 67262-29

Product Name: Aqua Chem Chlorinating Granules Plus

  • Active Ingredient(s)
    • BORAX PENTAHYDRATE
      • Guarantee/concentration 8 %
    • TRICHLORO-S-TRIAZINETRIONE
      • Guarantee/concentration 71.8 %

7. b) Type of formulation.

Granular

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

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

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Person mixed product with another granular shock product (non-BioLab) in a bucket and the mixture exploded on him.

To be determined by Registrant

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

No

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Medical Professional

2. Demographic information of data subject

Sex: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

  • Respiratory System
    • Symptom - Shortness of breath
  • Nervous and Muscular Systems
    • Symptom - Headache
  • Blood
    • Symptom - Acidosis
  • Skin
    • Symptom - Burns (superficial)

4. How long did the symptoms last?

>24 hrs <=3 days / >24 h <=3 jours

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

2

Day(s) / Jour(s)

7. Exposure scenario

Non-occupational

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

Application

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

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

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.)

Product was mixed in appropriately with another product and then water was added. Product is supposed to be applied directly to the pool.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

Product label warns against pre-dissolving and mixing with other products.