Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2019-2671
2. Registrant Information.
Registrant Reference Number: Rocky Mountain PC Case#: 6071653
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
Packaging Failure
4. Date registrant was first informed of the incident.
30-MAY-19
5. Location of incident.
Country: CANADA
Prov / State: UNKNOWN
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. 25831
PMRA Submission No.
EPA Registration No.
Product Name: Nufos 4E
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: Female
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
4. How long did the symptoms last?
Unknown / Inconnu
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
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)
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.)
Patients are relabeling what are supposed to be sealed jugs. Over the past week, patients have occasionally found a jug with a broken seal. There may have been a couple drops of product on the jug. Patients took the leaking just and set it aside, near where they were working. It was not until today that leaking jugs were pointed out to management. They are working in a large, well ventilated, chemical warehouse. 2 of the 12 patients say they have had headaches. One of these patients has a history of headaches.
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.
Other
2. Demographic information of data subject
Sex: Unknown
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
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?
Unknown
7. Exposure scenario
Occupational
8. How did exposure occur? (Select all that apply)
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
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.)
Patients are relabeling what are supposed to be sealed jugs. Over the past week, patients have occasionally found a jug with a broken seal. There may have been a couple drops of product on the jug. Patients took the leaking just and set it aside, near where they were working. It was not until today that leaking jugs were pointed out to management. They are working in a large, well ventilated, chemical warehouse. 2 of the 12 patients say they have had headaches. One of these patients has a history of headaches.
To be determined by Registrant
14. Severity classification.
15. Provide supplemental information here.
Subform VI: Packaging Failure
1. What is the type of packaging that failed?
Other / Autre
specify jug
2. Did packaging failure occur during?
Other
3. Did packaging failure result in?
potential exposure
4. Describe how the packaging failed and the surrounding circumstances, including a description of the potential injury or exposure.
Patients are relabeling what are supposed to be sealed jugs. Over the past week, patients have occasionally found a jug with a broken seal. There may have been a couple drops of product on the jug. Patients took the leaking just and set it aside, near where they were working. It was not until today that leaking jugs were pointed out to management. They are working in a large, well ventilated, chemical warehouse. 2 of the 12 patients say they have had headaches. One of these patients has a history of headaches.
For Registrant use only
5. Provide supplemental information here.