Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-3688

2. Registrant Information.

Registrant Reference Number: PROSAR Case # 1-23578520

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

Address: 1735 Market Street

City: Philadelphia

Prov / State: PA

Country: USA

Postal Code: 19103

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

Domestic Animal

4. Date registrant was first informed of the incident.

26-JUL-10

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

23-JUL-10

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. 24175      PMRA Submission No.       EPA Registration No.

Product Name: Dragnet FT Emulsifiable Concentrate Insecticide

• Active Ingredient(s)
  • PERMETHRIN

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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 III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Peekaboo

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

6

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

>3 days <=1 wk / >3 jours <=1 sem

11. List all symptoms

System

• Nervous and Muscular Systems
  • Symptom - Other
  • Specify - abnormal mentation/"not himself"
  • Symptom - Difficulty walking

12. How long did the symptoms last?

Unknown / Inconnu

13. Was medical treatment provided? Provide details in question 17.

Unknown

14. a) Was the animal hospitalized?

Unknown

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Unknown/Inconnu

16. How was the animal exposed?

Contact treat.area/Contact surf. traitée

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

1-23578520- The reporter, a pet owner, calls to report possible exposure of her animal to an insecticide containing the active ingredient permethrin. The caller indicates her indoor screen porch was treated with the product by a PCO six days prior to the initial contact with the registrant. Three days later her six year male peekapoo dog began to demonstrate signs of abnormal mentation ( "not acting himself") and difficulty walking up steps. The sign has persisted to the point of the initial contact with the registrant. The owner did not observe a discreet exposure, but indicates contact with the application area may be possible. The caller was advised the signs seen were inconsistent with dermal exposure to the active ingredient. The caller was advised to seek veterinary assistance in diagnosis and treatment. No further information is available.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Minor

19. Provide supplemental information here