Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-2307

2. Registrant Information.

Registrant Reference Number: 169

Registrant Name (Full Legal Name no abbreviations): Chemtura Canada Co./Cie

Address: 25 Erb Street

City: Elmira

Prov / State: Ontario

Country: Canada

Postal Code: N3B 3A3

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

Human

4. Date registrant was first informed of the incident.

14-MAY-12

5. Location of incident.

Country: UNITED STATES

Prov / State: OREGON

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.

Active(s)

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PMRA Registration No. 27924      PMRA Submission No.       EPA Registration No. 400-508

Product Name: Floramite

• Active Ingredient(s)
  • BIFENAZATE
    • Unknown

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7. b) Type of formulation.

Other (specify)

soluble concentrate

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Personal use / Usage personnel

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: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Rash

• Gastrointestinal System
  • Symptom - Irritated throat

4. How long did the symptoms last?

>1 wk <=1 mo / > 1 sem < = 1 mois

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)

Application

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

Oral

11. What was the length of exposure?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

>24 hrs <=3 days / >24 h <=3 jours

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.)

As stated from ()name) Poison and Drug Center: On May 5, 2012, caller stated her son accidentally sprayed himself with diluted product in the face (2 weeks ago). He immediately rinsed off after exposure. The son had throat irritation, and a rash to the face, head and stomach which started approximately 24 hours after exposure. (name) advised the caller that the symptoms were not likely related to the Floramite exposure. Caller wa sadvised that per the document http://www.epa.gov/opprd001/factsheets/bifenazte.pdf "Bifenazate possesses low acute toxicity by all routes of exposure (category IV) with no evidence of dermal sensitization potential. It is non-irritating to skin and minimally irritating to eyes."

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.