Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-1152

2. Registrant Information.

Registrant Reference Number: IRF174

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.

12-APR-13

5. Location of incident.

Country: UNITED STATES

Prov / State: NEW HAMPSHIRE

6. Date incident was first observed.

10-APR-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)

---

PMRA Registration No. 11423      PMRA Submission No.       EPA Registration No. 400-564

Product Name: Vitaflo 280

• Active Ingredient(s)
  • CARBATHIIN
    • Guarantee/concentration 15.59 %
  • THIRAM
    • Guarantee/concentration 13.25 %

---

7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Unknown / Inconnu

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

applied as a seed treatment

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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Irritated 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

Unknown

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

Contact with treated area

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.

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.)

Subject had ordered barley seed from Ontario to use as a mix for feed. He received seed treated with Vitaflo-280. He was exposed to the seed on his forearms not knowing it was treated. He had washed his arms but was experiencing slight irritation. He was concerned about the toxicity.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Subject was advised that Vitaflo-280 could cause skin irritation and that it was not especially toxic, and even less so with the amount on the seeds. Subject was advised to seek medical attention. Subject was told that the product contains thiram which can be absorbed through the skin. Subject was advised not to drink any alcohol as it may cause a negative reaction.