Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-1937

2. Registrant Information.

Registrant Reference Number: CCW

Registrant Name (Full Legal Name no abbreviations): Clearon Corporation

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.

17-SEP-07

5. Location of incident.

Country: UNITED STATES

Prov / State: TEXAS

6. Date incident was first observed.

17-SEP-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. 69470-19-75217

Product Name: PoolBrand Multi-Functional Chlorinating Granules12149

• 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.

5

Units: ppm

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).

Caller stated that she got a granule on the tip of her tongue (apparently during application). She had rinsed her tongue for almost 20 minutes, but described a small blister at the area of contact. No indication of how the material was handled, applied, the size of the pool being 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.

Data Subject

2. Demographic information of data subject

Sex: Female

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

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Blister
  • Specify - on tongue

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.

No

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)

Unknown

10. Route(s) of exposure.

Oral

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.)

Minimal information available aside from mention of slight blister at area of contact. Two days later, in a followup call, the patient indicated she was fine and the symptoms lasted for "a little while", but she had not noticed difficulty from the blister by the evening of 9/17/2007 (day of exposure).

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.