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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2020-3146

2. Registrant Information.

Registrant Reference Number: PMRA 21723

Registrant Name (Full Legal Name no abbreviations): Lonza LLC

Address: 412 Mount Kemble Avenue

City: Morristown

Prov / State: New Jersey

Country: United States

Postal Code: 07960

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

Human

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: UNITED STATES

Prov / State: ILLINOIS

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.

PMRA Registration No. 21723      PMRA Submission No.       EPA Registration No. 6836-66

Product Name: Bardac 205M

• Active Ingredient(s)
  • DIDECYL DIMETHYL AMMONIUM CHLORIDE
    • Unknown
  • DIOCTYL DIMETHYL AMMONIUM CHLORIDE
    • Unknown
  • N-ALKYL (40% C12, 50% C14, 10% C16) DIMETHYL BENZYL AMMONIUM CHLORIDE
    • Unknown
  • OCTYL DECYL DIMETHYL AMMONIUM CHLORIDE
    • 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.

Medical Professional

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Blister
  • Symptom - Burning skin
  • Symptom - Burns (2nd or 3rd degree)

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.

Skin

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.)

Hx: Caller is a NP and an urgent care clinic. She has a patient with a dermal exposure to his left forearm. He has 2nd degree burns. He was working with the product, a hose contacted his arm causing a 2 cm wide rope shaped that forms a backwards C the area is red with white blisters. There is another area near his wrist about 4-6 cm long the is worse, there are more blisters in that area. The areas surrounding the burns are also becoming red. There is no swelling. She would like treatment recommendations.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.