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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-3351

2. Registrant Information.

Registrant Reference Number: PMRA-IR20160309

Registrant Name (Full Legal Name no abbreviations): Thor GmbH

Address: Landwehrstrasse 1

City: Speyer

Country: Germany

Postal Code: D-67346

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

Human

4. Date registrant was first informed of the incident.

24-MAY-16

5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

6. Date incident was first observed.

09-MAR-16

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. 28013      PMRA Submission No.       EPA Registration No.

Product Name: ACTICIDE 14 Industrial Microbiocide

  • Active Ingredient(s)
    • 2-METHYL-4-ISOTHIAZOLIN-3-ONE
    • 5-CHLORO-2-METHYL-4-ISOTHIAZOLIN-3-ONE

7. b) Type of formulation.

Application Information

8. Product was applied?

Unknown

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

  • Skin
    • Symptom - Blister
    • Symptom - Red skin

4. How long did the symptoms last?

>1 wk <=1 mo / > 1 sem < = 1 mois

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)

Application

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Long-sleeve shirt

Chemical resistant gloves

Coveralls (non-chemical resistant)

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

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

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.)

Employee was replacing a part at the bottom of a piece of equipment. Valves were cut off but there was chemical residue left in the line. Several droplets of the chemical landed on the employee's shoulder and soaked through. Employee did not notice any burning or irritation and completed the job. Noticed raised, red skin while showering at home that night, approximately 4 hours after exposure. Next morning large blisters had formed and opened up on his shoulder and all down his arm to his wrist. Went to urgent care the day after exposure, then went to burn unit and eventually referred to the wound care unit. Employee had 4 weeks of recovery before his skin healed completely but returned to work after his visit to the wound care unit. Diagnosis was chemical burn.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

Both the product label and the SDS warn against product contact with skin. Contaminated clothing is to be removed immediately and skin is to be rinsed with plenty of water after exposure.