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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-7982

2. Registrant Information.

Registrant Reference Number: 202213

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

4. Date registrant was first informed of the incident.

22-JUN-07

5. Location of incident.

Country: UNITED STATES

Prov / State: TEXAS

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. 1021-1806-59144

Product Name: ELIMINATOR Wasp + Hornet Killer1021-1806-59144

  • Active Ingredient(s)
    • TETRAMETHRIN

7. b) Type of formulation.

Other (specify)

aerosol

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Res. - Out Home / Rés - à l'ext.maison

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?

Yes

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Mixed Breed

4. Number of animals affected

2

5. Sex

Male

6. Age (provide a range if necessary )

0.25

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

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

11. List all symptoms

System

  • General
    • Symptom - Death

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.

Unknown

14. a) Was the animal hospitalized?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

16. How was the animal exposed?

Other / Autre

specify Exposure not known to have occurred or witnessed. Exposure is based on speculation.

17. Provide any additional details about the incident

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

6/22/2007 2:04:25 PMCaller states that one her children used product on a piece of wood in the yard on the ground and unspecified period of time ago. Caller also has a litter of 3 month old puppies that were allowed to roam in the yard. Caller found one puppy dead yesterday and another one died today. They looked like they were sleeping when they died. Caller notes that there is no evidence of diarrhea or vomiting in the yard. The other 4 puppies appear to be OK.Caller admittedly is only speculating that these puppies somehow had contact with this piece of wood that was sprayed with the pesticide.Owner was instructed to take all of the puppies to the DVM right away.Attempts at following up with the owner on 7/11 and 7/16 were unsuccessful. Two messages for left requesting follow-up, but the owner never called back.


To be determined by Registrant

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

Death

19. Provide supplemental information here