Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2021-1615

2. Registrant Information.

Registrant Reference Number: Rocky Mountain PC Case#: 6199189

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.

09-APR-20

5. Location of incident.

Country: UNITED STATES

Prov / State: TEXAS

6. Date incident was first observed.

09-APR-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. 2793206

Product Name: Talstar P Professional Insecticide

• Active Ingredient(s)
  • BIFENTHRIN
    • Guarantee/concentration 7.9 %

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 432-1483

Product Name: Temprid

• Active Ingredient(s)
  • BETA-CYFLUTHRIN
    • Guarantee/concentration 10.5 %
  • IMIDACLOPRID
    • Guarantee/concentration 21 %

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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: 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).

Talstar P was sprayed inside the home. Temprid was sprayed outside the home. Applied 4.8.2020.

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

Other

2. Type of animal affected

Dog / Chien

3. Breed

Boxer

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

4

7. Weight (provide a range if necessary )

Unknown

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

• Cardiovascular System
  • Symptom - Cardiac arrest

• General
  • Symptom - Death

12. How long did the symptoms last?

Persisted until death

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

No

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

16. How was the animal exposed?

Other / Autre

specify Unknown

17. Provide any additional details about the incident

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

Dog found dead morning after home was treated.

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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