Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-0060

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.

29-AUG-08

5. Location of incident.

Country: UNITED STATES

Prov / State: KENTUCKY

6. Date incident was first observed.

29-AUG-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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 8622-41-7521723682

Product Name: 1 inch Brominating Tablets

• Active Ingredient(s)
  • SODIUM BROMIDE
    • Guarantee/concentration 92.5 %

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7. b) Type of formulation.

Tablet

Application Information

8. Product was applied?

Unknown

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Stuffy nose

• General
  • Symptom - Taste altered
  • Specify - unpleasant lingering taste in mouth

4. How long did the symptoms last?

>30 min <=2 hrs / >30 min <=2 h

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

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.

Respiratory

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.)

A pool maintenance worker opened a new container of the product; the vapor/gas present caused his eyes to sting. He took the product to his manager. She became congested and complained of an unpleasant taste in her mouth. The congestion cleared in approx. 90 min., but the taste lingered. The tablets were beginning to turn orange in color.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.