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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-0180

2. Registrant Information.

Registrant Reference Number: 2009-IR-01

Registrant Name (Full Legal Name no abbreviations): Nalco Canada Company

Address: 1055 Truman Street, PO Box 5002

City: Burlington

Prov / State: ON

Country: Canada

Postal Code: L7R 3Y9

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

Human

4. Date registrant was first informed of the incident.

09-JAN-09

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

08-JAN-09

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. 26428      PMRA Submission No.       EPA Registration No.

Product Name: Nalcon 7678

  • Active Ingredient(s)
    • 2-METHYL-4-ISOTHIAZOLIN-3-ONE
    • 5-CHLORO-2-METHYL-4-ISOTHIAZOLIN-3-ONE

7. b) Type of formulation.

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 II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Male

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

3. List all symptoms, using the selections below.

System

  • General
    • Symptom - Pain
    • Specify - immediate burning pain
  • Skin
    • Symptom - Red 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.

No

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)

Other

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Long-sleeve shirt

Long pants

Goggles

Chemical resistant gloves

10. Route(s) of exposure.

Skin

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.)

Repairing a biocide pump there was some residual pressure in the pipe that caused the chemical to spray through the clothes on to the right hand side wrist and knee causing immediate chemical burns. The clothes were removed and the areas were washed well and bandages were applied. The amount of product was estimated to be 10 -100 ml.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.