Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-2925

2. Registrant Information.

Registrant Reference Number: 2010-17

Registrant Name (Full Legal Name no abbreviations): BASF Canada

Address: 100 Milverton, 5th floor

City: Mississauga

Prov / State: ON

Country: Canada

Postal Code: L5R4H1

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

Human

4. Date registrant was first informed of the incident.

18-JUN-10

5. Location of incident.

Country: UNITED STATES

Prov / State: SOUTH CAROLINA

6. Date incident was first observed.

17-JUN-10

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. 2010-0616      EPA Registration No. 241-392

Product Name: Phantom

• Active Ingredient(s)
  • CHLORFENAPYR

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7. b) Type of formulation.

Liquid

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.

Medical Professional

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 - Diaphoresis

• Cardiovascular System
  • Symptom - Tachycardia

• General
  • Symptom - Fever

• Nervous and Muscular Systems
  • Symptom - Confusion

• Blood
  • Symptom - Hypokalemia
  • Specify - hyperkalemia

• General
  • Symptom - Death

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.

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

1

Day(s) / Jour(s)

7. Exposure scenario

Unknown

8. How did exposure occur? (Select all that apply)

Poisoning from ingestion of the pesticide

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

10. Route(s) of exposure.

Oral

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>2 hrs <=8 hrs / > 2 h < = 8 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.)

(age) Y old male accidentally ingested product from water bottle (1-2 mouthfuls;1-2oz?) in unknown form (suspect concentrated);later that evening he became confused, diaphoretic and began to develop fever-symptoms worsened over night and was brought into ER, then ICU.Patient expired 6-19.

To be determined by Registrant

14. Severity classification.

Death

15. Provide supplemental information here.