Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-5339

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-27602902

Registrant Name (Full Legal Name no abbreviations): HACCO, Inc.

Address: 110 Hopkins Drive

City: Randolph

Prov / State: Wisconsin

Country: USA

Postal Code: 53956

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

Human

4. Date registrant was first informed of the incident.

04-OCT-11

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

04-OCT-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. 61282-55

Product Name: BioSentry 904 Disinfectant

• Active Ingredient(s)
  • DIDECYL DIMETHYL AMMONIUM CHLORIDE
  • N-ALKYL(40% C12, 50% C14, 10% C16)DIMETHYLBENZYLAMMONIUM CHLORIDE
  • TRIBUTYLTIN OXIDE

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Pub. Area - Indoor/Zone publique - int

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

1-27602902- The reporter indicates exposure to a disinfectant containing the active ingredients didecyl dimethyl ammonium chloride, alkyl (C12-61%, C14-23%, C16-11%, C18-2.5%, C8 C10, 2.5%) dimethyl benzyl ammonium chloride, alkyl (C12-40%, C14-50%, C16-10%) dimethyl benzyl ammonium chloride, and bis-n-tributyltin oxide. The reporter indicated she was using the product diluted in water but then had mixed it with an unspecified product she referred to as odor eliminator. She described spraying and cleaning animal cages just prior to her call. The aroma associated with the mixed product was causing her to cough. The reporter was advised the mixing of cleaning supplies without specific manufacture recommendations is not recommended. She was advised to ventilate the work area thoroughly and of personal protective equipment recommended. The caller refused follow up. The caller did not clarify why and EPA registered product was being used in Canada. No further information is available.

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.

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 - Coughing

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

Unknown

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)

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.)

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.