Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2024-2488
2. Registrant Information.
Registrant Reference Number: Rocky Mountain PC Case#: 6807017
Registrant Name (Full Legal Name no abbreviations): FMC of Canada Limited
Address: 6755 Mississauga Road, Suite 204
City: Mississauga
Prov / State: ON
Country: Canada
Postal Code: L5N 7Y2
3. Select the appropriate subform(s) for the incident.
Human
4. Date registrant was first informed of the incident.
06-JUN-24
5. Location of incident.
Country: CANADA
Prov / State: SASKATCHEWAN
6. Date incident was first observed.
06-JUN-24
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)
PMRA Registration No. 16688
PMRA Submission No.
EPA Registration No.
Product Name: Pounce 384 EC
PMRA Registration No. 33225
PMRA Submission No.
EPA Registration No.
Product Name: Arrow All End
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. - 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).
He was applying dilute Pounce 384 EC and Arrow All End (by Adama). In fresh air when did this. Dermal exp only. He had on rubber gloves. Got all over arms and legs. Has showered since.
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
4. How long did the symptoms last?
Unknown / Inconnu
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)
Application
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
Chemical resistant gloves
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.)
Rash on wrists. Headache - may not have been related. Showered.
To be determined by Registrant
14. Severity classification.
Minor
15. Provide supplemental information here.