Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-0513

2. Registrant Information.

Registrant Reference Number: Ticket 3001

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.

30-JUN-11

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

30-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. Unknown

Product Name: HTH Sock It Shock Treatment

• Active Ingredient(s)
  • CALCIUM HYPOCHLORITE

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7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

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.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Coughing

4. How long did the symptoms last?

>30 min <=2 hrs / >30 min <=2 h

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

No

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)

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.

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.)

Person called the ACEAN line because he had used a warm bucket of water to mix two products inside of his home: Sock It and a brand of tablets called Aquarius. This had resulted in a reaction, and he had breathed in some of the fumes. This had happened one hour ago, and he was still experiencing some coughing. I advised him that he could remain in fresh air and sip on water, but that he should also consider seeking medical attention since his symptoms had persisted to this point in time. I also advised him to contact his local fire department for assistance with decontaminating his house, as there still appeared to be some lingering fumes. I also advised against pre-mixing products in the future, and to keep the ACEAN number on reference for any further questions.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Reaction occurred when pre-mixing 2 products in water before application to pool.