Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-4840

2. Registrant Information.

Registrant Reference Number: 2019-01

Registrant Name (Full Legal Name no abbreviations): 3313045 Nova Scotia Company

Address: #2400, 215-2nd Street

City: Calgary

Country: Canada

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

Human

4. Date registrant was first informed of the incident.

23-AUG-19

5. Location of incident.

Country: UNITED STATES

Prov / State: TENNESSEE

6. Date incident was first observed.

23-AUG-19

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.       PMRA Submission No.       EPA Registration No. Unknown

Product Name:

• Active Ingredient(s)
  • GLUTARALDEHYDE
    • Unknown

---

7. b) Type of formulation.

Liquid

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: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Asthma

• General
  • Symptom - Death

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Occupational

8. How did exposure occur? (Select all that apply)

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.

Respiratory

Unknown

11. What was the length of exposure?

Unknown / Inconnu

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.)

To be determined by Registrant

14. Severity classification.

Death

15. Provide supplemental information here.

Our product (which is registered with PMRA) was sold to a formulator, who blended our product with another company's product and an incident occurred. A worker was transferring product from the bulk tank storage to the truck and hadn't released the pressure prior to starting the transfer. So was sprayed with the product. He was asthmatic and also was not wearing a respirator as was required. He was taken to an eye wash station and then told to shower and change clothes. Then was sent back to work. He complained about trouble breathing. They took him in to air conditioning and gave him a breathing treatment. They called an ambulance, who attempted CPR and proceeded to the hospital. The man never regained consciousness.