Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2022-0169

2. Registrant Information.

Registrant Reference Number: Rocky Mountain PC Case#: 6490611

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.

22-NOV-21

5. Location of incident.

Country: UNITED STATES

Prov / State: NEW JERSEY

6. Date incident was first observed.

21-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. 279-3622

Product Name: Fyfanon EW Insecticide

• Active Ingredient(s)
  • MALATHION
    • Unknown

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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. - Out Home / Rés - à l'ext.maison

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

Caller reports he was exposed to Malathion on October 21st 2020, when a truck drove up and sprayed the Fyfanon EW Insecticide in front of his home. He was outside for about 30 minutes. At the time he was having some SOB, he refused to be seen in ER due to COVID. He has been having trouble breathing off and on through out the year. In July it got worse, and he now thinks he has damage to his heart, they are saying he as afib.

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: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Shortness of breath

• Cardiovascular System
  • Symptom - Arrhythmia

• Respiratory System
  • Symptom - Difficulty Breathing

4. How long did the symptoms last?

>6 mos / > 6 mois

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

Unknown

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)

Drift from the application site

Other

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?

>15 min <=2 hrs / >15 min <=2 h

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.)

At the time he was having some SOB, he refused to be seen in ER due to covid. He has been having trouble breathing off and on through out the year. In July it got worse, and he now thinks he has damage to his heart, they are saying he as afib.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

Outcome major, but not consisted with exposure to product.