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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-1230

2. Registrant Information.

Registrant Reference Number: 2017-02-24-a

Registrant Name (Full Legal Name no abbreviations): Chem-Aqua Div of NCH Canada Inc.

Address: 253 Orenda Road

City: Brampton

Prov / State: Ontario

Country: Canada

Postal Code: L6T 1E6

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

Human

4. Date registrant was first informed of the incident.

24-FEB-17

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

24-FEB-17

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. 27326      PMRA Submission No. 2007-7409      EPA Registration No. 1769-375

Product Name:

  • 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?

Yes

9. Application Rate.

Unknown

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

Site: Other / Autre

Préciser le type: Customer site inside mechanical room.

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

Subject added in a feeder MB-215 and two other non PCP products. He closed the lid and re-opened the valves in order to isolate. The lid was not properly closed and the product came out and fell to the ground and lightly on the subject and the piping.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Yes

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

3. List all symptoms, using the selections below.

System

  • Skin
    • Symptom - Other
    • Specify - Red spots on forehead

4. How long did the symptoms last?

<=30 min / <=30 min

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

No

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)

Goggles

Chemical resistant gloves

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.)

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.

Subject rinsed forehead after exposure because red spots appeared to be present. 30 minutes after the incident the spots were gone.