Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-2395

2. Registrant Information.

Registrant Reference Number: RF 180

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

Address: 25 Erb Street

City: Elmira

Prov / State: Ontario

Country: Canada

Postal Code: Elmira

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

Human

4. Date registrant was first informed of the incident.

06-SEP-13

5. Location of incident.

Country: UNITED STATES

Prov / State: NEW YORK

6. Date incident was first observed.

06-SEP-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. 27324      PMRA Submission No.       EPA Registration No. 400 508

Product Name: Floramite SC

• Active Ingredient(s)
  • BIFENAZATE

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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).

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: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Irritated 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?

No

6. b) For how long?

7. Exposure scenario

Unknown

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

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

Oral

11. What was the length of exposure?

Unknown / Inconnu

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.)

Subject called with concerns because her neighbors' tree had been sprayed with Floramite SC. She was concerned that the the drift would affect her and her organic garden. She claims that she was exposed and that her hands and face were burning. Symptoms resolved quickly after she rinsed off. She wanted to know information on how long she needed to wait before eating from her garden. She also had concerns about how many pears her son and husband had eaten that might have been effected by spray drift. The son and husband had no adverse effects.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.