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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-5556

2. Registrant Information.

Registrant Reference Number: 1-14896828

Registrant Name (Full Legal Name no abbreviations): Whitmire Micro-Gen Research Laboratories, INC

Address: 3568 Tree Court Industrial Blvd.

City: St. Louis

Prov / State: MO

Country: USA

Postal Code: 63122

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

Human

4. Date registrant was first informed of the incident.

14-MAY-07

5. Location of incident.

Country: UNITED STATES

Prov / State: TEXAS

6. Date incident was first observed.

13-MAY-07

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. 499470

Product Name: Prescription Treatment brand Cy-Kick Crack & Crevice Press. Residual

  • Active Ingredient(s)
    • CYFLUTHRIN
      • Guarantee/concentration .1 %

7. b) Type of formulation.

Other (specify)

Aerosol

Application Information

8. Product was applied?

Unknown

9. Application Rate.

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).

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.

Medical Professional

2. Demographic information of data subject

Sex: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

  • Respiratory System
    • Symptom - Burning throat
  • Gastrointestinal System
    • Symptom - Nausea
    • Symptom - Vomiting
  • General
    • Symptom - Taste altered
    • Specify - altered Taste

4. How long did the symptoms last?

>8 hrs <=24 hrs / > 8 h < = 24 h

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

Yes

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)

Contact with treated area

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?

Unknown / Inconnu

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.)

Patient presented after inhaling small amount of product on 5-13-2007. Patient experienced some burning in throat and altered taste along with nausea and vomiting. Vital signs and pulse were good. Caller hung up before patient info filled out or case number assigned.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.