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Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-5448

2. Registrant Information.

Registrant Reference Number: ProPharma Group case#: 1-53918760

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.

5. Location of incident.

Country: CANADA

Prov / State: QUEBEC

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.

PMRA Registration No. 24175      PMRA Submission No.       EPA Registration No.

Product Name: DRAGNET FT EMULSIFIABLE CONCENTRATE INSECTICIDE

• Active Ingredient(s)
  • PERMETHRIN

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: Male

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

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Confusion

• General
  • Symptom - Fatigue

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?

Unknown

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Pesticide Spill

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.)

1-53918760 - The reporter indicates an exposure to a pesticide containing the active ingredient permethrin. Approximately two weeks before the day of initial contact with the registrant, the reporter indicated the product has spilled in his car interior and he had been inhaling the fumes since then causing him confusion and fatigue. The reporter was advised to not use the car until it had been cleaned and to seek medical evaluation of his persistent symptoms. On follow-up call two days later, the reporter stated he had cleaned out his car and his symptoms improved, and he had seen a doctor, but lab results weren't back. No additional information is available.

To be determined by Registrant

14. Severity classification.

Moderate

15. Provide supplemental information here.