Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-0404

2. Registrant Information.

Registrant Reference Number: 342

Registrant Name (Full Legal Name no abbreviations): Arch Chemicals Inc.

Address: 5660 New Northside Drive, Suite 1100

City: Atlanta

Prov / State: Georgia

Country: U.S.A.

Postal Code: 30328

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

Human

4. Date registrant was first informed of the incident.

01-JUN-09

5. Location of incident.

Country: CANADA

6. Date incident was first observed.

01-JUN-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)

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PMRA Registration No. 22828      PMRA Submission No.       EPA Registration No.

Product Name: HTH Extra Super Shock for Swimming Pools

• Active Ingredient(s)
  • CALCIUM HYPOCHLORITE

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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.

Other

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Respiratory pain

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Non-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)

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.

Unknown / Inconnu

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.)

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

Caller's son inhaled HTH Dry Chlorine Tablets. Upon opening he tried to smell the product and inhaled it. We were not able to get a lot code. After being in fresh air for 15 minutes it hurt him to take deep breaths so we suggested that she seek medical attention. We advised to take the ACEAN number with her and tell the doctor to call if he needed an MSDS or needed to speak with our on call doctor.