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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2016-3353

2. Registrant Information.

Registrant Reference Number: 1809845

Registrant Name (Full Legal Name no abbreviations): McLaughlin Gormley King Company

Address: 8810 Tenth Ave North

City: Minneapolis

Prov / State: MN

Country: USA

Postal Code: 55427-4319

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

25-APR-16

5. Location of incident.

Country: UNITED STATES

Prov / State: ARIZONA

6. Date incident was first observed.

09-APR-16

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.       PMRA Submission No.       EPA Registration No. 1021-1674-8845

Product Name: Hot Shot Bedbug & Flea Fogger

  • Active Ingredient(s)
    • ESFENVALERATE
      • Guarantee/concentration .1 %
    • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
      • Guarantee/concentration .16 %
    • PIPERONYL BUTOXIDE
      • Guarantee/concentration .1 %
    • PYRETHRINS
      • Guarantee/concentration .05 %
    • PYRIPROXYFEN
      • Guarantee/concentration .1 %

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).

Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding application.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Yes

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

  • Nervous and Muscular Systems
    • Symptom - Muscle weakness
  • Respiratory System
    • Symptom - Shortness of breath
  • Skin
    • Symptom - Blister
  • Respiratory System
    • Symptom - Other
    • Specify - exacerbation of COPD

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

9

Day(s) / Jour(s)

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

What was the activity? Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding the activity

Drift from the application site

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 / <=15 min

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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.)

6/2/2016 A report dated 4/25/2016 was forwarded for documentation. The report states that caller lives in an apartment complex. Caller had returned from 7 days in the hospital being treated for chronic obstructive pulmonary disease. Caller's neighbor used a fogger. Caller developed shortness of breath, weakness, and blisters on her face and chest. Caller returned to the hospital and was hospitalized for 9 days for exacerbation of chronic obstructive pulmonary disease symptoms. Caller was given oxygen and breathing treatments every 3 hours.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews. Direct exposure to this pesticide is not evident in this incident. The delayed onset of the patient symptoms after application is not suggestive of toxicity nor would they be expected symptoms should contact to airborne spray have occurred. Usually complications such as immediate onset of acute eye, skin and respiratory irritation may be seen following exposure to spray drift but these symptoms were not reported in this incident.