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
- 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.