Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-0939

2. Registrant Information.

Registrant Reference Number: BUL

Registrant Name (Full Legal Name no abbreviations): Buckman Laboratories of Canada, Ltd.

Address: 351 Joseph-Carrier Street

City: Vaudreuil-Dorion

Prov / State: Quebec

Country: Canada

Postal Code: J7V 5V5

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

Human

4. Date registrant was first informed of the incident.

06-FEB-18

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

6. Date incident was first observed.

11-DEC-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)

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PMRA Registration No. 19002      PMRA Submission No.       EPA Registration No.

Product Name: Busan 1081 Liquid Microbicide

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

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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.

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 - Red skin
  • Symptom - Rash
  • Symptom - Burning skin

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.

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)

Other

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

Goggles

Chemical resistant gloves

Chemical resistant coveralls

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

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

12. Time between exposure and onset of symptoms.

>8 hrs <=24 hrs / > 8 h < = 24 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.)

Occurred during the cleaning of the pumping system, the old product container (mother bin) and the containment basin. The system was rinsed with water and there were some product residuals left in the old mother bin and containment basin. During the cleaning, it may be possible that there was some splashing of chemical diluted with water. The subject believe he had an indirect contact while disposing of the PPE, and some of the chemical got on his shirt. His shirt was wet because of the sweating under his PPE. The subject believes the wet shirt contributed to enhance the chemical spreading on his shirt and body. He went back home and shower at the end of the day. He did not feel any burn or rashes but 24 hours after, the skin on his chest started to get red and 48 hours after rashes and 1 and 2nd degree burns appeared. No prescription medication were provided. Polysporin and Vitamin E cream were applied.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.

After 2 months, the skin has healed but it created a hyper-pigmentation on the affected region.