Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-3243

2. Registrant Information.

Registrant Reference Number: 52-AD140

Registrant Name (Full Legal Name no abbreviations): RBF International Lte

Address: 780, rue Nobel

City: St-Jerome

Prov / State: Quebec

Country: Canada

Postal Code: J7Z 7A3

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

Human

Packaging Failure

4. Date registrant was first informed of the incident.

16-JUL-15

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

09-JUL-15

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. 20683.01      PMRA Submission No.       EPA Registration No.

Product Name: Algicide Liquide 40 % Polyquat

• Active Ingredient(s)
  • POLY-[DICHLORURE D'OXYETHYLENE(DIMETHYLIMINIO)ETHYLENE(DIMETHYLIMINIO)ETHYLENE]

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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: Female

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

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Flushed

4. How long did the symptoms last?

>30 min <=2 hrs / >30 min <=2 h

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

Yes

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 pants

10. Route(s) of exposure.

Skin

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.)

Voici la description complete (en anglais) de la personne expose: We followed the MSDS for treating the employee. She flashed the area with water for the recommended time stated on the MSDS. The area was a little red but she said that it did not hurt. We continued to check with the person threw out the day to make sure that there was no change on how she was feeling. She said that she was feeling fine and that there was no pain. The amount that spilled was less then a liter.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Subform VI: Packaging Failure

1. What is the type of packaging that failed?

Bottle-plastic / Bouteille-plastique

2. Did packaging failure occur during?

Storage

3. Did packaging failure result in?

potential injury

4. Describe how the packaging failed and the surrounding circumstances, including a description of the potential injury or exposure.

Le bouchon ¿¿¿¿tait mal vis¿¿¿¿. Lorsque l'employ¿¿¿¿e a ramass¿¿¿¿ le contenant, son contenu s'est d¿¿¿¿vers¿¿¿¿ sur sa jambe. Ce qui a caus¿¿¿¿ une rougeur sur la peau.

For Registrant use only

5. Provide supplemental information here.