Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-4108
2. Registrant Information.
Registrant Reference Number: ProPharma Group case#: 1-48828497
Registrant Name (Full Legal Name no abbreviations): FMC Corporation
Address: 2929 Walnut Street
City: Philadelphia
Prov / State: Pennsylvania
Country: USA
Postal Code: 19104
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
02-JUL-17
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
02-JUL-17
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)
PMRA Registration No. 24175
PMRA Submission No.
EPA Registration No.
Product Name: DRAGNET FT EMULSIFIABLE CONCENTRATE INSECTICIDE
7. b) Type of formulation.
Application Information
8. Product was applied?
Unknown
9. Application Rate.
10. Site pesticide was applied to (select all that apply).
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
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
Unknown
8. How did exposure occur? (Select all that apply)
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
11. What was the length of exposure?
Unknown / Inconnu
12. Time between exposure and onset of symptoms.
<=30 min / <=30 min
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.)
1-48828497 - The reporter indicates an exposure to a pesticide containing the active ingredient permethrin. On the day of the initial contact with the registrant, the reporter indicated she had gotten the product concentrate on her leg. The reporter stated she had washed the product off for about 5 minutes, but about 30 minutes after the initial exposure, she was experiencing burning skin where the product had made contact. The reporter was advised the symptom should resolve within 24 hours, and if it persists, medical attention should be sought. No follow-up was done. No additional information is available.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.