Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-6179

2. Registrant Information.

Registrant Reference Number: PROSAR case: 1-42299163

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.

Human

4. Date registrant was first informed of the incident.

28-OCT-15

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

14-OCT-15

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. Unknown

Product Name: Dragnet

• 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: Pub. Area - Indoor/Zone publique - int

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

• Gastrointestinal System
  • Symptom - Irritated throat

• Skin
  • Symptom - Irritated skin

• Respiratory System
  • Symptom - Coughing

• Skin
  • Symptom - Red skin

• Respiratory System
  • Symptom - Other
  • Specify - possible sinus infection

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Contact with treated area

What was the activity? office work

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.)

1-42299163 - The reporter indicated that she was exposed to an insecticide containing the active ingredient permethrin. The reporter stated that the product was sprayed at night time in an office adjacent to hers 14 days prior to initial contact with the registrant. The following day the reporter noticed the odor and was bothered by it. The same office was treated again this time while the reporter was at her desk, six days prior to initial contact with the registrant. By that afternoon, the reporters throat and skin were irritated and she was coughing. The symptoms were still present at the time of the initial call and the reporter also noted, on the morning of initial contact, that her neck was red. The reporter went to the doctor two days prior to her call and was being treated for a possible sinus infection. No additional information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.