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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-5572

2. Registrant Information.

Registrant Reference Number: OND

Registrant Name (Full Legal Name no abbreviations): Nalco Canada Company

Address: 1055 Truman Street

City: Burlington

Prov / State: Ontario

Country: Canada

Postal Code: L7R 3Y9

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


4. Date registrant was first informed of the incident.


5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.


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.


PMRA Registration No. 17338      PMRA Submission No.       EPA Registration No.

Product Name: Nalco 7330 Slimicide

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


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?


Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.


2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • Skin
    • Symptom - Blister
    • Symptom - Burning skin
    • Symptom - Red skin

4. How long did the symptoms last?

Unknown / Inconnu

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


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


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.


11. What was the length of exposure?

>2 hrs <=8 hrs / >2 h <=8 h

12. Time between exposure and onset of symptoms.

>2 hrs <=8 hrs / > 2 h < = 8 h

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.)

The exposure occurred during cleaning of a trench which contained product that had leaked from a faulty delivery system. At the time of cleaning the leak was not identified. There may have been up to 10 gallons in the trench. The Trench cleaning commenced before 3pm. The person affected remove the grids over the trench, lost his footing and stepped into the contaminated trench. He was wearing leather work boots which became saturated and he did not replace them until after his shift. Symptoms onset: 5 pm -irritation to his feet, 5:30-6 pm redness; after 7 pm -severe burning in both feet while showering, then blistering, blisters 1-2 inches diameter; 10pm -went to hospital. Medical treatment instructions: rest foot, keep clean and dry, limit wearing of footwear.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.