Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-4559

2. Registrant Information.

Registrant Reference Number: ProPharma Group case#: 1-44846040

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.

13-JUL-16

5. Location of incident.

Country: CANADA

Prov / State: SASKATCHEWAN

6. Date incident was first observed.

13-JUL-16

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. 67760-28

Product Name: NUFOS 4E INSECTICIDE

• Active Ingredient(s)
  • CHLORPYRIFOS

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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: Res. - In Home / Rés. - à l'int. maison

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.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Cardiovascular System
  • Symptom - Chest tightness

4. How long did the symptoms last?

>1 wk <=1 mo / > 1 sem < = 1 mois

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

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.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

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.)

1-44846040- The reporter indicated an exposure to an insecticide with the active ingredient chlorpyrifos. The reporter indicated he purchased the product in Canada. The reporter applied the diluted product approximately one week before initial contact with the registrant and may have inhaled some. The evening of the day of application, the reporter experienced tightness in the chest. On the day of initial contact with the registrant, the reporter indicated the symptom had been on an off since application, but was particularly bad that day. The reporter had not sought medical attention. The reporter was told the product might cause respiratory irritation and was advised to seek medical attention as the symptoms had persisted. On follow-up two days later, the reporter noted that his symptoms were improving and he felt completely better, but he had not seen a doctor. No additional information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.