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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-0453

2. Registrant Information.

Registrant Reference Number: PMRA 28319

Registrant Name (Full Legal Name no abbreviations): Arch Chemicals Inc.

Address: 5660 New Northside Drive, Suite 1100

City: Atlanta

Prov / State: GEORGIA

Country: U.S.A.

Postal Code: 30328

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

Human

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: UNITED STATES

Prov / State: IDAHO

6. Date incident was first observed.

Unknown

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. 28319      PMRA Submission No.       EPA Registration No. 1258-1288

Product Name: HTH Algae Guard 3X Concentrate

• Active Ingredient(s)
  • N-ALKYL (5% C12, 60% C14, 30% C16, 5% C18) DIMETHYL BENZYL AMMONIUM CHLORIDE
    • Guarantee/concentration 15 %
  • N-ALKYL (68% C12, 32% C14) DIMETHYL ETHYLBENZYL AMMONIUM CHLORIDE
    • Guarantee/concentration 15 %

7. b) Type of formulation.

Liquid

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: >6 <=12 yrs / > 6 < = 12 ans

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Burning skin

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Contact with treated area

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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.)

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.