Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-4450

2. Registrant Information.

Registrant Reference Number: 11-02

Registrant Name (Full Legal Name no abbreviations): Recochem Inc.

Address: 850 Montee de Liesse

City: Montreal

Prov / State: Quebec

Country: Canada

Postal Code: H4T 1P4

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

Human

4. Date registrant was first informed of the incident.

13-SEP-11

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

30-AUG-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)

---

PMRA Registration No. 2525      PMRA Submission No.       EPA Registration No.

Product Name: Naphthalene mothballs

• Active Ingredient(s)
  • NAPHTHALENE

---

7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

800

Units: g

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).

from the email sent to Canadian Tire: I purchased two packs of Napthalene Mothballs 400 Grams. I spread them underneath my backyard patio to stave off skunks and racoons.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

No

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: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Difficulty Breathing
  • Specify - respiratory blockage

• General
  • Symptom - Lethargy

• Nervous and Muscular Systems
  • Symptom - Headache
  • Symptom - Dizziness

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.

Yes

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)

Contact with treated area

What was the activity? the person exposed had spreaded the balls under their deck maybe a few days prior, the exposure occured the first time they sat on the deck

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

None

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

>15 min <=2 hrs / >15 min <=2 h

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.)

this information is from the email sent to CTC: 08/30/2011 02:18:54 PM I am writing to you regarding a recent purchase. I purchased two packs of Napthalene Mothballs 400 Grams. I spread them underneath my backyard patio to stave off skunks and racoons. My husband and I like to sit in the back at night. After the first night of sitting out, we both had severe upper respiratory blockage, headaches, dizziness and general lethargy. Upon further reseach (spoke to poison control, telehealth ON, Toxicology Researcher) we came to the conclusion that the mothballs are a highly toxic product. In fact, it can be fatal to children and pets and cause other long term health problems. Also, it has been banned in many areas of Europe. My concern was that there was NO warnings on this product. Worse, the packaging was so substandard, there was no plastic seal..just a thin cardboard box. I am shocked that this is something that's overlooked. Please contact me [name] [number].

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

The wife of the person exposed said she did not mind if PMRA called her. [name] [number]

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: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Difficulty Breathing
  • Specify - respiratory blockage

• General
  • Symptom - Lethargy

• Nervous and Muscular Systems
  • Symptom - Headache
  • Symptom - Dizziness

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.

Yes

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Unknown

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

Contact with treated area

What was the activity? the person exposed had spreaded the balls under their deck maybe a few days prior, the exposure occured the first time they sat on the deck

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

None

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

>15 min <=2 hrs / >15 min <=2 h

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.)

this information is from the email sent to CTC: 08/30/2011 02:18:54 PM I am writing to you regarding a recent purchase. I purchased two packs of Napthalene Mothballs 400 Grams. I spread them underneath my backyard patio to stave off skunks and racoons. My husband and I like to sit in the back at night. After the first night of sitting out, we both had severe upper respiratory blockage, headaches, dizziness and general lethargy. Upon further reseach (spoke to poison control, telehealth ON, Toxicology Researcher) we came to the conclusion that the mothballs are a highly toxic product. In fact, it can be fatal to children and pets and cause other long term health problems. Also, it has been banned in many areas of Europe. My concern was that there was NO warnings on this product. Worse, the packaging was so substandard, there was no plastic seal..just a thin cardboard box. I am shocked that this is something that's overlooked. Please contact me [name] [number].

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.