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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-0405
2. Registrant Information.
Registrant Reference Number: 544
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.
24-JUN-09
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
24-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)
PMRA Registration No. 23324
PMRA Submission No.
EPA Registration No.
Product Name: HTH Extra Super Shock for Swimming Pools
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: Female
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
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
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.
Eye
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.
Minor
15. Provide supplemental information here.
We advised per the MSDS to rinse the water gently with fresh water for 15-20 minutes and continue on to the doctor. We advised to take the ACEAN number with her so we could provide the doctor with a MSDS or put them in contact with our doctor if needed.