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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-1938

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.

Domestic Animal

4. Date registrant was first informed of the incident.

20-MAR-08

5. Location of incident.

Country: UNITED STATES

Prov / State: KANSAS

6. Date incident was first observed.

20-MAR-08

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.       PMRA Submission No.       EPA Registration No. 69470-20-37655

Product Name: Tropi Clear Granular DiChlor12149

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

7. b) Type of formulation.

Granular

Application Information

8. Product was applied?

No

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 III: Domestic Animal Incident Report

1. Source of Report

Medical Professional

2. Type of animal affected

Dog / Chien

3. Breed

Collie

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Oral

9. What was the length of exposure?

>15 min <=2 hrs / >15 min <=2 h

10. Time between exposure and onset of symptoms

<=30 min / <=30 min

11. List all symptoms

System

  • Gastrointestinal System
    • Symptom - Vomiting

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.

Yes

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Fully Recovered / Complètement rétabli

16. How was the animal exposed?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

Veterinarian called stating that a client had called in regard to their dog. The dog had chewed on and ingested "some" of the product from a bag of granular dichlor. Owners indicated the animal did not ingest much, indicated the animal was vomiting. Animal was seen in a vet clinic and no evidence of any burns were noted in the oral cavity. Animal was placed on sucralfate and cimetidine to be certain.


To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Minor

19. Provide supplemental information here