Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2837

2. Registrant Information.

Registrant Reference Number: PROSAR Case #:1-26551001

Registrant Name (Full Legal Name no abbreviations): Matson, LLC

Address: 45620 S. E. North Bend Way ¿ P.O. Box 1820

City: North Bend

Prov / State: Washington

Country: USA

Postal Code: 98045

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

Human

4. Date registrant was first informed of the incident.

19-JUN-11

5. Location of incident.

Country: UNITED STATES

Prov / State: WASHINGTON

6. Date incident was first observed.

19-JUN-11

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.       EPA Registration No. 8119-11

Product Name: Corrys Slug Snail Death

• Active Ingredient(s)
  • METALDEHYDE
    • Guarantee/concentration 3.25 %

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7. b) Type of formulation.

Bait

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Res. - Out Home / Rés - à l'ext.maison

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

• Gastrointestinal System
  • Symptom - Nausea
  • Symptom - Vomiting

• General
  • Symptom - Sweating

• Gastrointestinal System
  • Symptom - Salivating excessively

• Renal System
  • Symptom - Urinary incontinence

• General
  • Symptom - Fatigue

• Nervous and Muscular Systems
  • Symptom - Loss of coordination
  • Specify - stroke like incoordination

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

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

Application

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

Unknown

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

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.)

1-26551001- The reporter, an emergency medical technician, indicated a patient had been exposed to a pesticide containing the active ingredient metaldehyde. The reporter indicated he had just been called to the scene where an adult male patient had reported having applied the product to his residential lawn earlier the evening prior to his initial contact with the registrant. The patient had reported windy conditions during application and had felt he had inhaled dusts of the product. The patient reported he had developed symptoms of nausea, vomiting, sweatiness and salivation one hour prior to the initial contact with the registrant. The reporter was advised the signs seen would not be expected to be precipitated by inhalation of dusts of the product. The level of exposure following the described event would be expected to be insufficient to elicit a systemic effect. It was advised the patient be evaluated by a physician. On follow up the patient indicated he was admitted to the hospital (duration not clarified). He reported his doctors did not think his symptoms were related to his exposure to the product. He additionally experienced 'stroke like incoordination', vomiting and urinary incontinence. He reports he was given supplemental oxygen but does not know what additional was done for him. He reports he has been discharged and all symptoms have resolved but for ongoing fatigue. It was reiterated to the patient that the symptoms seen would not be expected following the described exposure. He was encouraged to continue to work with his doctor to determine the cause of his illness and the appropriate care. No further information is available.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.