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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-0515

2. Registrant Information.

Registrant Reference Number: Ticket 3219

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.

19-JUL-11

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

19-JUL-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 Liquid Shock (Scheduled product)

  • Active Ingredient(s)
    • SODIUM HYPOCHLORITE

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.

Other

2. Demographic information of data subject

Sex: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

  • Eye
    • Symptom - Burning eye

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)

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 about 5 minutes after her husband splashed HTH Liquid Shock in his eyes. He was in the shower rinsing his eyes and had already removed his contacts. He was complaining of his eyes burning. I read from the MSDS acute medical effects and advised to rinse for 15-20 minutes and seek medical care or calling poison control. To take ACEAN number in case further information or consult is needed.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.