Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-0507

2. Registrant Information.

Registrant Reference Number: Ticket 2609

Registrant Name (Full Legal Name no abbreviations): Arch Chemicals, Incorporated

Address: 5660 New Northside Drive, Suite 1100

City: Atlanta

Prov / State: Georgia

Country: USA

Postal Code: 30328

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

Human

4. Date registrant was first informed of the incident.

28-APR-11

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

01-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.       EPA Registration No. Unknown

Product Name: Sock It

• Active Ingredient(s)
  • CALCIUM HYPOCHLORITE

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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.

Medical Professional

2. Demographic information of data subject

Sex: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Burns (superficial)
  • Symptom - Burning skin
  • Specify - burning sensation
  • Symptom - Hyperesthesia
  • Specify - temperature sensitivity

4. How long did the symptoms last?

>6 mos / > 6 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

Occupational

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

Pesticide Spill

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

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

Dr. contacted Arch Chemicals regarding a patient that had gotten Sock It on her hands. This had happened in June 2010 while the woman (a retail store employee) was working at the checkout lane. Apparently she had not been able to wash her hands within 15 minutes of exposure, and this had resulted in a burn. In the months since then, the woman has gone on to experience problems with her hands such as a burning sensation and temperature sensitivity. Dr. wanted to know if these problems could be long term symptoms from the exposure to the Sock It. I faxed the product's MSDS to Dr. for her review and advised her that an Arch toxicologist could be contacted if she needed additional information. No follow up available.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.