Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-0509

2. Registrant Information.

Registrant Reference Number: Ticket 2682

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.

21-MAY-11

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

21-MAY-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.       PMRA Submission No.       EPA Registration No. Unknown

Product Name: HTH Granular Chlorinator (Scheduled product)

• Active Ingredient(s)
  • CALCIUM HYPOCHLORITE

---

7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

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.

Other

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Anxiety
  • Specify - people were "shaken" but not injured

4. How long did the symptoms last?

<=30 min / <=30 min

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

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.

Eye

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.)

A woman called the ACEAN line after her husband added hot water to chlorine granules in the kitchen. She stated there was an explosion and they could not enter the house. Advised them to not to attempt to enter the house and to immediately call the Fire Department. She spoke English and her husband only spoke French. (name) and her husband seemed shaken but not injured. Was unable to get the label name of the chlorine granules. Also attempted to determine if the product had a do not mix label. She did not know but stated the store where they purchased the product instructed them to add hot water. (name) was obviously in a rush to call the Fire Department after being instructed to do so. Was unable to get additional information. Advised her to have the ACEAN number available should the Fire Department require it. Follow up call- She states she did call the Fire Department after her phone call to the ACEAN line. She states the Fire Department opened the house and cleared out the fumes. She also states she was given oxygen and felt fine after that. She, nor her husband feel any effects today. She states the brand of chlorine granules was HTH. She confirmed that the dealer told them to dissolve the product in warm water.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Exposure due to misuse of product: pre-dissolved with hot water.