Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2022-5633

2. Registrant Information.

Registrant Reference Number: 2022-CNS-1

Registrant Name (Full Legal Name no abbreviations): Timber Specialties Limited

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.

16-SEP-22

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

16-SEP-22

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. 34022      PMRA Submission No.       EPA Registration No.

Product Name: CUT-N-SEAL WOOD PRESERVATIVE

• Active Ingredient(s)
  • COPPER, PRESENT AS BASIC COPPER CARBONATE
  • N-ALKYL (67% C12, 25% C14, 7% C16, 1% C18) DIMETHYL BENZYL AMMONIUM CHLORIDE

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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.

Other

2. Demographic information of data subject

Sex: Male

Age: >1 <=6 yrs / > 1 < = 6 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Vomiting

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

Non-occupational

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

Poisoning from ingestion of the pesticide

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

10. Route(s) of exposure.

Skin

Oral

11. What was the length of exposure?

<=15 min / <=15 min

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.)

Grandmother of the victim called stating she thinks her grandson stuck his hand in the Cut-N-Seal Wood Preservative container and licked his fingers. The child vomited once. The grandmother called the local hospital, who told her to call the number on the label. Timber Specialties advised her to call Poison Control. The child was given a glass of water and a glass of milk.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.