Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2016-1698
2. Registrant Information.
Registrant Reference Number: ProPharma case: 1-42876388
Registrant Name (Full Legal Name no abbreviations): FMC Corporation
Address: 1735 Market Street
City: Philadelphia
Prov / State: Pennsylvania
Country: USA
Postal Code: 19103
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
06-JAN-16
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
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)
PMRA Registration No.
PMRA Submission No.
EPA Registration No. Unknown
Product Name: Dragnet
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: Pub. Area - Indoor/Zone publique - int
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: Unknown
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Respiratory System
- Symptom - Shortness of breath
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
Non-occupational
8. How did exposure occur? (Select all that apply)
Contact with treated area
What was the activity? Daily living
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.
Respiratory
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.)
1-42876388 - The reporter, a paramedic, indicated that two people were exposed to an insecticide containing the active ingredient permethrin. The reporter stated that the product had been applied inside a hotel at some unknown time and at the time of the call two people were complaining of shortness of breath. The reporter had not yet arrived on scene so he could not provide additional information on the patients, the severity of their symptoms and what if any treatment was needed. The reporter was advised, that if the hotel had not been ventilated appropriately after product application, exposure to the fumes may cause short term respiratory irritation. No additional information is available.
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.
Medical Professional
2. Demographic information of data subject
Sex: Unknown
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Respiratory System
- Symptom - Shortness of breath
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
Non-occupational
8. How did exposure occur? (Select all that apply)
Contact with treated area
What was the activity? Daily living
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.
Respiratory
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.)
1-42876388 - The reporter, a paramedic, indicated that two people were exposed to an insecticide containing the active ingredient permethrin. The reporter stated that the product had been applied inside a hotel at some unknown time and at the time of the call two people were complaining of shortness of breath. The reporter had not yet arrived on scene so he could not provide additional information on the patients, the severity of their symptoms and what if any treatment was needed. The reporter was advised, that if the hotel had not been ventilated appropriately after product application, exposure to the fumes may cause short term respiratory irritation. No additional information is available.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.