Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2021-6084

2. Registrant Information.

Registrant Reference Number: X

Registrant Name (Full Legal Name no abbreviations): X

Address: X

City: X

Prov / State: X

Country: X

Postal Code: X

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

Human

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

15-OCT-21

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.       PMRA Submission No.       EPA Registration No.

Product Name: CHROMATED COPPER ARSENATE (UNSPECIFIED FORMULATION)

• Active Ingredient(s)
  • ARSENIC ACID
  • CHROMIC ACID
  • COPPER (PRESENT AS CUPRIC OXIDE)
  • CUPRIC OXIDE

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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: Unknown / Inconnu

Préciser le type: Treated wood

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

On October 15, 2021, the X, X, Saanichton, BC X in Saanichton, BC sold a pencil post treated with chromated copper arsenate (CCA), a treated article, to X of X for residential use. X, who sold the post to X, is also implicated. No indication was given by X at the time of purchase by X of the type of treatment on the post, the risks involved with handling, nor any safety recommendations. There was also no label on the post indicating that it was CCA treated. The X employee who loaded the post into the vehicle did so with his bare hands.

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

• Liver
  • Symptom - Other
  • Specify - Symptoms of liver damage

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Unknown

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

Contact with treated area

What was the activity? Exposure to ash generated by the previous burning of CCA treated posts

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.)

Potential irritation to the skin, mechanical rubbing potentially increasing skin irritation, potential dermatitis or allergic skin reactions in sensitized individuals. X is currently experiencing symptoms of recent liver damage which may be attributable to arsenic/copper/chromium poisoning from exposure to ash generated by the previous burning of CCA treated posts. These underlying health symptoms raise the level of concern for X generated by this recent exposure to CCA.

To be determined by Registrant

14. Severity classification.

15. Provide supplemental information here.

Photographs and other information submitted by reporter.