Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-6990

2. Registrant Information.

Registrant Reference Number: 1-15104333

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.

13-JUL-07

5. Location of incident.

Country: UNITED STATES

Prov / State: WASHINGTON

6. Date incident was first observed.

12-JUL-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. 499304

Product Name: Prescription Treatment brand Cy-Kick CS Controlled Release Cyfluthrin

• Active Ingredient(s)
  • CYFLUTHRIN
    • Guarantee/concentration 6 %

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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.

Other

2. Demographic information of data subject

Sex: Male

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

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Burning skin
  • Symptom - Itchy skin

4. How long did the symptoms last?

>2 hrs <=8 hrs / > 2 h < = 8 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)

Pesticide Spill

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Long-sleeve shirt

10. Route(s) of exposure.

Skin

11. What was the length of exposure?

>2 hrs <=8 hrs / >2 h <=8 h

12. Time between exposure and onset of symptoms.

>2 hrs <=8 hrs / > 2 h < = 8 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.)

Coworker had a back pack leak, product spilled onto his entire back 7/12/07 while at work. Stated employee did not wash product off for approx 6 hours. Showered when he got home and in am, used self treatment with Aloe. Went to MD and received a cream for the exposure and helped greatly, returned to work. Case closed.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.