Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2021-1613

2. Registrant Information.

Registrant Reference Number: Rocky Mountain PC Case#: 6169484

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.

15-FEB-20

5. Location of incident.

Country: UNITED STATES

Prov / State: NORTH CAROLINA

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)

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PMRA Registration No. 29473      PMRA Submission No.       EPA Registration No. 279-9636

Product Name: T-Square

• Active Ingredient(s)
  • THIFENSULFURON METHYL
    • Guarantee/concentration 50 %
  • TRIBENURON METHYL
    • Guarantee/concentration 25 %

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7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Agricultural-Outdoor/Agricole-extérieur

Préciser le type: Wheat

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

1 month prior to call received on 2-15-2020, pet owner sprayed his wheat field including a dead deer in the field. Dog was found eating the carcass.

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

Unknown

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

9

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• Nervous and Muscular Systems
  • Symptom - Difficulty walking

• Gastrointestinal System
  • Symptom - Anorexia

12. How long did the symptoms last?

>1 wk <=1 mo / > 1 sem < = 1 mois

13. Was medical treatment provided? Provide details in question 17.

Yes

14. a) Was the animal hospitalized?

Yes

14. b) How long was the animal hospitalized?

Unknown

15. Outcome of the incident

Euthanised / Euthanasie

16. How was the animal exposed?

Other / Autre

specify Ate carcass of dead deer that was in the wheat field

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

Vet stated that dog had numerous tumors and did not feel tumors were related to the exposure.

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To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification

Death

19. Provide supplemental information here