Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-1923

2. Registrant Information.

Registrant Reference Number: CCW

Registrant Name (Full Legal Name no abbreviations): Clearon

Address: 95 MacCorkle Avenue SW

City: S. Charleston

Prov / State: WV

Country: USA

Postal Code: 25303

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

Human

4. Date registrant was first informed of the incident.

13-APR-07

5. Location of incident.

Country: UNITED STATES

Prov / State: LOUISIANA

6. Date incident was first observed.

13-APR-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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 69470-200-75217

Product Name: Pool Brand Quick Dissolving Shock12149

• Active Ingredient(s)
  • SODIUM DICHLORO-S-TRIAZINETRIONE
    • Guarantee/concentration 100 %

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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).

Patient indicated that the wind was blowing when she opened the bag and some of the material was blown into her eyes. Complained of blurred vision.

To be determined by Registrant

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

Yes

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: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Burn on the eye
  • Symptom - Blurred vision

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

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

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.

Eye

11. What was the length of exposure?

<=15 min / <=15 min

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.)

Minimal details regarding the exposure were provided. Patient evaluated at an urgent care facility on 4/13/2007. Ocular burn noted during examination. Patient given a prescription for an unspecified eyedrop. Patient indicated she would followup with an eye specialist on 4/16/2007. Continued to complain of slightly blurred vision on 4/15/2007

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

(see above)