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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2022-6241
2. Registrant Information.
Registrant Reference Number: 269675
Registrant Name (Full Legal Name no abbreviations): Innovative Water Care, LLC
Address: 1400 Bluegrass Lakes Parkway
City: Alpharetta
Prov / State: Georgia
Country: US
Postal Code: 30004
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
08-AUG-225. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
08-AUG-22Product 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: HTH pH Increaser
- Active Ingredient(s)
- SODIUM CARBONATE
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: Res. - Out Home / Rés - à l'ext.maison
Préciser le type: Pool
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
The product was applied at the pool in a unknown rate, pool turned white and had sediment settling on the bottom, dealer told to vacuum and add fresh water. He did so, waiting another day before entering the pool and stated he and his wife had some burning after enter the pool.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.
Data Subject
2. Demographic information of data subject
Sex: Male
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Burning skin
4. How long did the symptoms last?
>2 mos and <=6mos />2 mois et <=6mois
5. Was medical treatment provided? Provide details in question 13.
No
6. a) Was the person hospitalized?
No
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Application
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?
>1 mo <= 6 mos / > 1 mois < = 6 mois
12. Time between exposure and onset of symptoms.
>8 hrs <=24 hrs / > 8 h < = 24 h
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.)
About 2 months before the call the Consumer added an overdose of 8 year old HTH pH Increaser. The pool turned white and had sediment settling on the bottom, his dealer told him to vacuum and add fresh water. He did so, waiting another day before entering the pool and stated he and his wife had some burning sensations on their feet which has continued over the past two months, coming and going. His wife also has been getting dizzy some. He stated he did add HTH Stabilizer but not sure if it was before the HTH pH Increaser or after.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.
Subform II: Human Incident Report (A separate form for each person affected)
1. Source of Report.
Data Subject
2. Demographic information of data subject
Sex: Female
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Burning skin
- Nervous and Muscular Systems
- Symptom - Dizziness
4. How long did the symptoms last?
>2 mos and <=6mos />2 mois et <=6mois
5. Was medical treatment provided? Provide details in question 13.
No
6. a) Was the person hospitalized?
No
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Application
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?
>1 mo <= 6 mos / > 1 mois < = 6 mois
12. Time between exposure and onset of symptoms.
>8 hrs <=24 hrs / > 8 h < = 24 h
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.)
About 2 months before the call the Consumer added an overdose of 8 year old HTH pH Increaser. The pool turned white and had sediment settling on the bottom, his dealer told him to vacuum and add fresh water. He did so, waiting another day before entering the pool and stated he and his wife had some burning sensations on their feet which has continued over the past two months, coming and going. His wife also has been getting dizzy some. He stated he did add HTH Stabilizer but not sure if it was before the HTH pH Increaser or after.
