Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-4557

2. Registrant Information.

Registrant Reference Number: ProPharma Group case#: 1-44832119

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.

08-JUL-16

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

07-JUL-16

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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PMRA Registration No. 30421      PMRA Submission No.       EPA Registration No. Unknown

Product Name: Onguard PC5

• Active Ingredient(s)
  • PIPERONYL BUTOXIDE
  • PYRETHRINS

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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 II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Irritated skin

• Eye
  • Symptom - Irritated eye

• Respiratory System
  • Symptom - Irritated throat

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?

7. Exposure scenario

Non-occupational

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

Contact with treated area

Amount of time between application and contact 8

Hour(s) / Heure(s)

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.

Skin

Eye

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.)

1-44832119 - The reporter indicated an exposure to an insecticide with the active ingredient permethrin. A second insecticide with the active ingredients pyrethrins and piperonyl butoxide was also applied, but is not manufactured by the registrant. The reporter indicated that his home had been sprayed with the two products one day before initial contact with the registrant. The reporter reentered his home eight hours after application and experienced irritation of his eyes, throat, and skin. After ventilating the home overnight, the reporter said he reentered the home on the day of initial contact with the registrant and did not experience any symptoms. The reporter was advised that it would be safe to reenter the property once the products had dried and that treated surfaces could be wiped off. No follow-up was attempted. No additional information is available.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.