Health Canada
www.hc-sc.gc.ca
Common menu bar links
Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2018-1488
2. Registrant Information.
Registrant Reference Number: ProPharma Group case#: 1-51751587
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.
21-MAR-185. Location of incident.
Country: CANADA
Prov / State: ALBERTA
6. Date incident was first observed.
Unknown
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. Unknown
Product Name: DRAGNET FT EMULSIFIABLE CONCENTRATE INSECTICIDE
- Active Ingredient(s)
- PERMETHRIN
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: Female
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Nervous and Muscular Systems
- Symptom - Muscle twitching
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 28
Hour(s) / Heure(s)
What was the activity? Re-entry into the home
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.
Unknown
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.)
1-51751587 - The reporter indicated she was exposed to an insecticide containing the active ingredient permethrin. Eight days before the day of initial contact with the registrant, the reporter indicated a pest control officer sprayed her home with the diluted product. The reporter indicated she did not return to the home for twenty-eight hours, then cleaned and aired out her residence. An unknown number of days before the day of initial contact, the reporter developed facial twitching which resolved, but indicated that is not an unusual symptom for her. No additional information is available.
To be determined by Registrant
14. Severity classification.
Moderate
15. Provide supplemental information here.
Subform II: Human Incident Report (A separate form for each person affected)
1. Source of Report.
Other
2. Demographic information of data subject
Sex: Male
Age: <=1 yr / < = 1 an
3. List all symptoms, using the selections below.
System
- Gastrointestinal System
- Symptom - Vomiting
- Skin
- Symptom - Pallor
4. How long did the symptoms last?
>24 hrs <=3 days / >24 h <=3 jours
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 28
Hour(s) / Heure(s)
What was the activity? Re-entry into the home
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.
Unknown
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.)
1-51751587 - The reporter indicated her son was exposed to an insecticide containing the active ingredient permethrin. Eight days before the day of initial contact with the registrant, the reporter indicated a pest control officer sprayed her home with the diluted product. The reporter indicated she and her child did not return to the home for twenty-eight hours, then she cleaned and aired out her residence. An unknown number of days before the day of initial contact, the reporter¿¿¿¿¿¿s son developed pale skin and vomited once. The pale skin resolved after three days. No additional information is available.
To be determined by Registrant
14. Severity classification.
Moderate
15. Provide supplemental information here.
Subform II: Human Incident Report (A separate form for each person affected)
1. Source of Report.
Other
2. Demographic information of data subject
Sex: Female
Age: Unknown / Inconnu
3. List all symptoms, using the selections below.
System
- General
- Symptom - Lethargy
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 28
Hour(s) / Heure(s)
What was the activity? Re-entry into the home.
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.
Unknown
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.)
1-51751587 - The reporter indicated her daughter was exposed to an insecticide containing the active ingredient permethrin. Eight days before the day of initial contact with the registrant, the reporter indicated a pest control officer sprayed her home with the diluted product. The reporter indicated she and her child did not return to the home for twenty-eight hours, then she cleaned and aired out her residence. An unknown number of days before the day of initial contact, the reporter¿¿¿¿¿¿s daughter developed lethargy which has resolved. No additional information is available.
To be determined by Registrant
14. Severity classification.
Minor
