Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-6558

2. Registrant Information.

Registrant Reference Number: 2019-CCA

Registrant Name (Full Legal Name no abbreviations): Timber Specialties Li mited

Address: 35 Crawford Crescent, P.O. BOX 520

City: Campbellville

Prov / State: Ontario

Country: Canada

Postal Code: L0P 1B0

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

Human

4. Date registrant was first informed of the incident.

29-SEP-19

5. Location of incident.

Country: UNITED STATES

Prov / State: SOUTH CAROLINA

6. Date incident was first observed.

Unknown

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. 19612      PMRA Submission No.       EPA Registration No. 3008-34

Product Name: Wood treated with Timber Specialties K-33 (C-60) Wood Preservative

• Active Ingredient(s)
  • ARSENIC PENTOXIDE
    • Guarantee/concentration 13 %
  • CHROMIC ACID
    • Guarantee/concentration 15.34 %
  • CUPRIC OXIDE
    • Guarantee/concentration 8.39 %

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7. b) Type of formulation.

Other (specify)

Wood treated with product

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: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Cancer

• Nervous and Muscular Systems
  • Symptom - Depression
  • Symptom - Muscle weakness

• General
  • Symptom - Death
  • Symptom - Malaise

• Gastrointestinal System
  • Symptom - Other
  • Specify - Tooth decay

4. How long did the symptoms last?

Persisted until death

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

Unknown

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)

Unknown

10. Route(s) of exposure.

Skin

Respiratory

11. What was the length of exposure?

>1 yr / > 1 an

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.)

Based on allegations raised in a lawsuit, Mr. (name) claimed to have worked as a carpenter. During his work, he allegedly sawed, cut, chopped, drilled, sanded, handled, etc. CCA treated wood. The lawsuit claims that his exposure to CCA treated wood caused his cancer, Acute Myelocytic Leukemia (AML). Injuries and conditions listed in the lawsuit include: loss of strength, loss of enjoyment of life, sickness, tooth decay, depression, numerous painful treatments including a bone marrow transplant, isolation in a hospital clean room, a compromised immune system, and the deprivation of his ability to function without assistance. The lawsuit claims that the cancer and injuries listed above caused Mr. (name)'s death.

To be determined by Registrant

14. Severity classification.

Death

15. Provide supplemental information here.

KPC was named as one of several defendants in a lawsuit filed by (name). Mrs. (name)'s husband, (name) died of cancer on 9/22/2016. Mrs. (name) claims that on or about September 2014 Mr. (name) was diagnosed with AML and believes wood treated with KPC and/or other companies' CCA caused or contributed to Mr. (name)'s cancer. The KPC legal team did not receive notice of this lawsuit until on or about 8/29/2019. The notice was not given to the Regulatory Manager until 11/19/2019.