Print | Need Larger Text?

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-7229

2. Registrant Information.

Registrant Reference Number: ProPharma Group case#: 1-46000594

Registrant Name (Full Legal Name no abbreviations): FMC Corporation

Address: 2929 Walnut Street

City: Philadelphia

Prov / State: Pennsylvania

Country: USA

Postal Code: 19104

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

Human

4. Date registrant was first informed of the incident.

5. Location of incident.

Country: UNITED STATES

Prov / State: ARKANSAS

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.

PMRA Registration No.       PMRA Submission No.       EPA Registration No. 279-3388

Product Name: PURGE III INSECTICIDE

• Active Ingredient(s)
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • Guarantee/concentration 3.05 %
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration 1.95 %
  • PYRETHRINS
    • Guarantee/concentration .975 %

7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Unknown

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.

Data Subject

2. Demographic information of data subject

Sex: Female

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

3. List all symptoms, using the selections below.

System

• Cardiovascular System
  • Symptom - Cardiac arrest
  • Symptom - Other
  • Specify - Clogged arteries

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

Occupational

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

Other

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.)

1-46000594- The reporter indicated an exposure to an insecticide with the active ingredients piperonyl butoxide, N-octyl bicycloheptene dicarboximide, and pyrethrins. Approximately 5 months before the day of initial contact with the registrant, the reporter indicated her boss installed a dispenser that sprayed the product at work several times a day. The reporter estimates she was sprayed three to four times a day for about one month. Approximately 4 months before the day of initial contact with the registrant, the reporter had cardiac arrest with clogged arteries. The reporter indicated she had never had any heart problems before this. The reporter was advised that this is an unexpected reaction to the product and she should continue to work with her physician. No follow-up was done. No additional information is available.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.