Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-0616

2. Registrant Information.

Registrant Reference Number: 2015-1

Registrant Name (Full Legal Name no abbreviations): BASF Canada

Address: 100 Milverton Dr, 5th floor

City: Mississauga

Prov / State: Ontario

Country: Canada

Postal Code: L5R4H1

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

Human

4. Date registrant was first informed of the incident.

19-JAN-15

5. Location of incident.

Country: UNITED STATES

Prov / State: COLORADO

6. Date incident was first observed.

15-NOV-14

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. 30664      PMRA Submission No.       EPA Registration No. 241-392

Product Name: Phantom termiticide insecticide

• Active Ingredient(s)
  • CHLORFENAPYR

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PMRA Registration No. 30664      PMRA Submission No.       EPA Registration No. 7969-285

Product Name: Phantom pressurized insecticide

• Active Ingredient(s)
  • CHLORFENAPYR

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7. b) Type of formulation.

Liquid

Other (specify)

pressurized spray

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Res. - In Home / Rés. - à l'int. maison

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

the wife of deceased mentioned they were using this product in the home for bed bugs. Apparently she was diluting it before use, but he was not. He had no direct exposure to the product other than not diluting it prior to use.

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.

Medical Professional

2. Demographic information of data subject

Sex: Male

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

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Confusion

• General
  • Symptom - Fever
  • Symptom - Death

• Cardiovascular System
  • Symptom - Other
  • Specify - coronary artery disease

4. How long did the symptoms last?

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

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

2

Day(s) / Jour(s)

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)

Unknown

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

>2 hrs <=8 hrs / >2 h <=8 h

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.)

Doctor reports that the patient came to the ER on and passed away on . He is not sure when the patient used the product prior to coming to the ER and does not know how long after the patient used the product he started to develop symptoms. The only symptoms he developed were confusion and fever. They did not determine a cause of death while in the hospital, but his post-mortem exam revealed coronary artery disease as the cause of death.

To be determined by Registrant

14. Severity classification.

Death

15. Provide supplemental information here.

the product is not expected to cause death or the symptoms reported that lead to the patient's death, even if product was not properly diluted.