Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-5560

2. Registrant Information.

Registrant Reference Number: 1-15011833

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.

16-JUN-07

5. Location of incident.

Country: UNITED STATES

Prov / State: TEXAS

6. Date incident was first observed.

11-JUN-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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 499290

Product Name: Prescription Treatment brand 565 Plus XLO Formula 2

• Active Ingredient(s)
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • Guarantee/concentration 1 %
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration 1 %
  • PYRETHRINS
    • Guarantee/concentration .5 %

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7. b) Type of formulation.

Liquid

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: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Loss of appetite

• General
  • Symptom - Sleepiness

• Unknown
  • Symptom - Other
  • Specify - sore sternum

• General
  • Symptom - Lightheadedness

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?

Unknown

6. b) For how long?

7. Exposure scenario

Occupational

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

Application

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?

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

12. Time between exposure and onset of symptoms.

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

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.)

Caller said that 24 hrs post use, developed symptoms of lightheadness, sleepy, no appetite and sore sternum. Recommended to see Doctor but caller declined a case number. Follow up call, wife stated original caller in hospital but not related to product exposure.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.