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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2009-2733
2. Registrant Information.
Registrant Reference Number: 2009-IR-02
Registrant Name (Full Legal Name no abbreviations): Nalco Canada Company
Address: 1055 Truman Street, PO Box 5002
City: Burlington
Prov / State: Ontario
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.
22-JUL-095. Location of incident.
Country: CANADA
Prov / State: SASKATCHEWAN
6. Date incident was first observed.
21-JUL-09Product 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. 29188 PMRA Submission No. EPA Registration No.
Product Name: Nalco 7330 Cooling Water and Industrial Process Water Slimicide
- 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
- Skin
- Symptom - Itchy skin
- Symptom - Tingling skin
- Specify - itchy - only when long sleeves are worn or abrasion of skin area. Still ongoing - if I've perspired and am wearing sleeves or put on sleeves it is slightly itchy. If my skin is dry does not seem to be itchy as much. Itchy being not so bad I want to scratch - mostly just tingly type sensation.
4. How long did the symptoms last?
>1 wk <=1 mo / > 1 sem < = 1 mois
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)
Pesticide Spill
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
Coveralls (non-chemical resistant)
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.
>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.)
Pails were located under the stair well in the chemical storage room. He reached under the stair railing to get a pail when he noticed that the lid spout had a hole in it. When he set the chemical down, some chemical splashed up on his Nomex coveralls. It is estimated that approximately 100 ¿ 200 mL of liquid splashed out of the pail with approximately 50% of what splashed out of the pail landed on his coveralls, boots and gloves. He immediately removed his Nomex coveralls and washed his arm in a near-by sink to dilute the potentially exposed area ¿ left forearm and hand. Approximately 2 to 3 minutes passed between time of exposure and the start of the water rinse. He was instructed to go a nearby medical clinic with a MSDS for (#) and seek medical advice as requested in the MSDS. Dr. (name) MD examined the area on the arm that was possibly exposed and recommended continued hydration/rinsing to ensure minimal ingress into skin area. He was instructed to check back with the clinic the next day to follow up to see if a rash or sensitive area had developed. He has not noticed any chemical burn at the site of contact. The only symptoms at the site of contact on the arm are itchy skin when wearing long sleeved shirts.
To be determined by Registrant
14. Severity classification.
Minor
