Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-0516

2. Registrant Information.

Registrant Reference Number: Ticket 3382

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.

04-AUG-11

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

04-AUG-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?

Yes

9. Application Rate.

Unknown

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

Site: Res. - Out Home / Rés - à l'ext.maison

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

This granular product was being poured into pool as application method. Amount of product or size of pool unknown.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Yes

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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Eye
  • Symptom - Bloodshot eye
  • Symptom - Foreign body sensation in eye

4. How long did the symptoms last?

<=30 min / <=30 min

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.

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.)

Person called the ACEAN line 20 minutes after the wind blew a granule of HTH Sock It into her eye as she was putting it into the pool. She states that she has a sensation like something in her eye and her eye is bloodshot. I read the symptoms for eye exposure and the first aid measures from the MSDS and gave her the poison control number and advised she call them or seek medical attention. I advised her if she does seek medical attention to take the products container and the ACEAN phone number with her in case the Dr. needs an MSDS or needs to speak to an Arch toxicologist.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.