Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-6992

2. Registrant Information.

Registrant Reference Number: 1-15284701

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.

29-AUG-07

5. Location of incident.

Country: UNITED STATES

Prov / State: IOWA

6. Date incident was first observed.

26-AUG-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.

Product Name: PTb 565 Plus XLO Pressurized Contact Insecticide 499-310

• Active Ingredient(s)
  • D-TRANS ALLETHRIN
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • Guarantee/concentration 1 %
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration 1 %
  • PYRETHRINS
    • Guarantee/concentration .25 %

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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: Male

Age: <=1 yr / < = 1 an

3. List all symptoms, using the selections below.

System

• Gastrointestinal System
  • Symptom - Diarrhea
  • Symptom - Vomiting

4. How long did the symptoms last?

>3 days <=1 wk / >3 jours <=1 sem

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)

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.

Unknown

11. What was the length of exposure?

>1 wk <=1 mo / > 1 sem < = 1 mois

12. Time between exposure and onset of symptoms.

>24 hrs <=3 days / >24 h <=3 jours

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.)

Mother called hospital with sick baby two days after application of PTb 565. This patient was seen in hospital, mother contacted a nurse at the hospital by phone who in turn contacted the company on behalf of the parent.

To be determined by Registrant

14. Severity classification.

Minor

15. Provide supplemental information here.