Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2020-4733

2. Registrant Information.

Registrant Reference Number: Rocky Mountain PC Case#:6289276

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.

01-OCT-20

5. Location of incident.

Country: CANADA

Prov / State: BRITISH COLUMBIA

6. Date incident was first observed.

01-OCT-20

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.       PMRA Submission No.       EPA Registration No. Unknown

Product Name: Dragnet Spray, Not Other Specified

• Active Ingredient(s)
  • PERMETHRIN

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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).

This morning someone came and applied Dragnet - doesn't know exact name of product. Applied it under the sink indoors and outdoors as well as bathroom. 5hrs later caller came back to apartment and it was dried. Was cleaning up the bathroom at 11pm and then got into the shower. Showered for an hour in the tub where the product had been sprayed.

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

• Skin
  • Symptom - Tingling skin

4. How long did the symptoms last?

>8 hrs <=24 hrs / > 8 h < = 24 h

5. Was medical treatment provided? Provide details in question 13.

No

6. a) Was the person hospitalized?

No

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 12

Hour(s) / Heure(s)

What was the activity? Showering

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

<=15 min / <=15 min

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.)

Immediate onset of feet tingling, washed only after recommended during call with medical line. Recommended to apply topical Vitamin E oil, did not as of call back hours later.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.