Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2009-0022
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.
10-JUN-08
5. Location of incident.
Country: UNITED STATES
Prov / State: NEW JERSEY
6. Date incident was first observed.
10-JUN-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. 69470-20-7521712149
Product Name: PoolBrand quick dissolving shock
- Active Ingredient(s)
- SODIUM DICHLORO-S-TRIAZINETRIONE
- Guarantee/concentration 100 %
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).
A pool was treated on 6/7/2008) using the product. Later, two children went into the pool. The chlorine content was not checked prior to entry on 6/7/2008. On 6/8/2008 the children used the pool. Late evening on 6/8/2008, the parent noted burns or irritations on the top part of the gemale's body, in the arms pits, around the chest, on the arms and on the back and neck. The male child had burns or irritations between the legs where the swim suit would rub. Caller speculated that the swim suits may have not been rinsed between visits to the pool, and asked if the pool material could have caused the irritations. Medical advice was sought; hydrocortisone cream appears to have provided relief. Children taken to visit the physician on 6/7/2008.
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.
Other
2. Demographic information of data subject
Sex: Female
Age: >6 <=12 yrs / > 6 < = 12 ans
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Inflammation of the skin
- Symptom - Pain
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?
No
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Contact with treated area
What was the activity? swimming in treated pool
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
10. Route(s) of exposure.
Skin
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
>8 hrs <=24 hrs / > 8 h < = 24 h
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.)
No information available regarding medical treatment other than application of hydrocortizone cream.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.