Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2017-6098
2. Registrant Information.
Registrant Reference Number: ProPharma Group case#: 1-49676157
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.
Domestic Animal
4. Date registrant was first informed of the incident.
12-SEP-17
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
12-SEP-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. 24360
PMRA Submission No.
EPA Registration No. Unknown
Product Name: DRAGNET FT EMULSIFIABLE CONCENTRATE
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. - Out Home / Rés - à l'ext.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
Dachshund
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
7
7. Weight (provide a range if necessary )
14
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
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
1-49676157 - The reporter, a pet owner, indicates an exposure to a pesticide containing the active ingredient permethrin. One day before the day of the initial contact with the registrant, the reporter indicated the product was sprayed outside his home and about 9 hours later, his 14-pound, 7-year-old, male Dachshund dog was allowed in the sprayed area. On the day of initial contact with the registrant, the reporter indicated the dog had vomited. The reporter was advised that small ingestions of the product might cause minor stomach upset, but if the symptoms persisted, veterinary evaluation should be sought. No additional information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here