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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-0492

2. Registrant Information.

Registrant Reference Number: Prosar 1-20977849

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.


4. Date registrant was first informed of the incident.


5. Location of incident.

Country: CANADA


6. Date incident was first observed.


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.

Product Name: Dragnet (non-specific)

  • Active Ingredient(s)

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


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).

The product was applied by a Pest Control Operator on 08/07/2009.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?


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.


  • Nervous and Muscular Systems
    • Symptom - Difficulty talking
  • Eye
    • Symptom - Red eye
  • Gastrointestinal System
    • Symptom - Dry mouth
    • Symptom - Nausea
  • Nervous and Muscular Systems
    • Symptom - Trembling
  • General
    • Symptom - Other
    • Specify - Burning sensation throughout body
  • Skin
    • Symptom - Dermatitis

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


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

Contact with treated area

Amount of time between application and contact 14

Hour(s) / Heure(s)

What was the activity? re-entry

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)


10. Route(s) of exposure.


11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>24 hrs <=3 days / >24 h <=3 jours

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.)

1-20977849: A reporter called on 12/09/2009 to report her exposure to an insecticide containing the active ingredient Permethrin. According to the reporter, the product was applied inside her apartment by a Pest Control Operator on 08/07/2009. The reporter waited 14 hours following application before returning to the apartment. On 08/09/2009, the reporter developed abnormal speech and red eyes. She went to the emergency room (diagnosis and treatment details were not provided) and had the apartment cleaned. The reporter's signs worsened at an unspecified time to include dry mouth, nausea, trembling, a burning sensation throughout her body, and dermatitis on her knees and elbows. The reporter stated that she moved out of her apartment one month prior to the report and has been staying with friends. The reporter was advised of the active ingredient. The reporter was also advised that dermal absorption of the active ingredient is slow, but dermal exposure to wet product may result in a temporary numbness, tingling, itching, or burning sensation that typically resolves on its own within 24 hours. Dermal exposure to wet product may result in dermatitis in susceptible individuals. The duration of signs described are not expected. With exposure to dry product, the signs described are not expected. Inhalation of product would also not be expected to result in the signs described. The reporter was advised to continue working with her physician to determine the cause of the signs. No further information was obtained.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.