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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2017-2790

2. Registrant Information.

Registrant Reference Number: 1985995

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.

Domestic Animal

Packaging Failure

4. Date registrant was first informed of the incident.

02-FEB-17

5. Location of incident.

Country: UNITED STATES

Prov / State: MICHIGAN

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)

PMRA Registration No.       PMRA Submission No.       EPA Registration No. 1021-2597-3

Product Name: BLKBB-32

  • Active Ingredient(s)
    • D-PHENOTHRIN
      • Guarantee/concentration .4 %
    • IMIDACLOPRID
      • Guarantee/concentration .05 %
    • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
      • Guarantee/concentration 1 %

7. b) Type of formulation.

Application Information

8. Product was applied?

No

9. Application Rate.

Unknown

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

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?

Unknown

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Cat / Chat

3. Breed

Unknown

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Skin

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

  • Gastrointestinal System
    • Symptom - Vomiting
  • General
    • Symptom - Death
  • Nervous and Muscular Systems
    • Symptom - Muscle tremors

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?

Unknown

15. Outcome of the incident

Died

16. How was the animal exposed?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

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

5/19/2017 The following report was forwarded for documentation. The report states that caller purchased a container of the product for use on bed bugs. In the middle of the night when caller's cats noticed that the bugs were active, caller tried to spray them with the product. The sprayer did not work. Caller took the product back to the store, and exchanged it for another container. The following night the sprayer did not work. Caller exchanged it for a third container. That night, the third container did not spray. Caller removed the cap, and was chasing bugs with the open container. Caller accidentally spilled the bottle in the dark, and one of caller's cats got product on her leg and feet. She ran and hid, and licked the product off of herself. The cat began convulsing and vomiting, and died within 20 minutes.


To be determined by Registrant

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

Death

19. 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.

Subform VI: Packaging Failure

1. What is the type of packaging that failed?

Can / Cannette

2. Did packaging failure occur during?

Use of Product

3. Did packaging failure result in?

potential exposure

4. Describe how the packaging failed and the surrounding circumstances, including a description of the potential injury or exposure.

5/19/2017 The following report was forwarded for documentation. The report states that caller purchased a container of the product for use on bed bugs. In the middle of the night when caller's cats noticed that the bugs were active, caller tried to spray them with the product. The sprayer did not work. Caller took the product back to the store, and exchanged it for another container. The following night the sprayer did not work. Caller exchanged it for a third container. That night, the third container did not spray. Caller removed the cap, and was chasing bugs with the open container. Caller accidentally spilled the bottle in the dark, and one of caller's cats got product on her leg and feet. She ran and hid, and licked the product off of herself. The cat began convulsing and vomiting, and died within 20 minutes.

For Registrant use only

5. 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.