Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-6583

2. Registrant Information.

Registrant Reference Number: OND

Registrant Name (Full Legal Name no abbreviations): NALCO CANADA CO.

Address: 1055 Truman Street

City: Burlington

Prov / State: Ontario

Country: Canada

Postal Code: L7R 3Y9

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

Human

4. Date registrant was first informed of the incident.

25-NOV-13

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

25-NOV-13

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. 27674      PMRA Submission No.       EPA Registration No.

Product Name: TOWERBROM 991

• Active Ingredient(s)
  • AVAILABLE CHLORINE, PRESENT AS TRICHLORO-S-TRIAZINETRIONE
  • SODIUM BROMIDE

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7. b) Type of formulation.

Application Information

8. Product was applied?

No

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: Male

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

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Difficulty Breathing

• Nervous and Muscular Systems
  • Symptom - Headache

• Gastrointestinal System
  • Symptom - Nausea

4. How long did the symptoms last?

>8 hrs <=24 hrs / > 8 h < = 24 h

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

Occupational

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)

Long-sleeve shirt

Long pants

Goggles

Chemical resistant gloves

10. Route(s) of exposure.

Respiratory

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.)

Male was exposed for 10 minutes to fumes. Went to company nurse. She checked his blood oxygen level -was OK. He took Tylenol for headache. He went back to work. No time loss. He had tight chest breathing but took some inhalers that night. All better next day. The exposure occurred because an outside line was frozen and the solution in the line, containing the product, backed up and leaked onto the floor. The person became nauseated when he walked into the spill area.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.