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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-4970

2. Registrant Information.

Registrant Reference Number: PROSAR Case #: 1-27043005

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.


4. Date registrant was first informed of the incident.


5. Location of incident.

Country: CANADA

Prov / State: ALBERTA

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. Unknown

Product Name: Dragnet FT (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).

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: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • Respiratory System
    • Symptom - Respiratory irritation
    • Specify - raspy voice
    • Symptom - Difficulty Breathing
    • Specify - "not comfortable breathing"

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 1.5

Day(s) / Jour(s)

What was the activity? re-entering application area (home/residence)

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.

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.)

1-27043005- The reporter indicated she was exposed to an insecticide continuing the active ingredient permethrin. The reporter indicated she returner to her home after the product had been applied to her home to address bed bugs in her home. She indicated she re-entered the area within seven hours of application and encountered a visible haze and an offensive aroma. She left the home and returned the next day. She reported at that point the aroma was not as significant but that she noted her ¿¿¿throat was raspy¿¿? and she was not ¿¿¿comfortable breathing¿¿?. The caller was unable to elaborate the rate used by the applicator of the product. She was advised when used as the label directs the product ha a wide margin of safety. The caller indicated she rarely has sensitivity issues but found the aroma unbearable. The caller was advised on proper methods of ventilating the home and cleaning the application area. The caller did not provide any further follow up. No further information is available.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.