Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2008-0601
2. Registrant Information.
Registrant Reference Number: 258606
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.
08-NOV-07
5. Location of incident.
Country: UNITED STATES
Prov / State: CALIFORNIA
6. Date incident was first observed.
07-NOV-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.
Product Name: BLACK FLAG KILLS MOSQUITOS FLIES GNATS
- Active Ingredient(s)
- PERMETHRIN
- Guarantee/concentration .2 %
- TETRAMETHRIN
- Guarantee/concentration .2 %
7. b) Type of formulation.
Liquid
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Res. - In Home / Rés. - à l'int. 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
Bird / Oiseau
3. Breed
Parakeet
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
1
7. Weight (provide a range if necessary )
1.00
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
<=15 min / <=15 min
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
No
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 Unclear how bird was exposed to material if product was not sprayed directly around the cage.
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
11/8/2007Caller sprayed product in his living room, and found his parakeet dead the following day. Bird was in no apparent distress the day the product was used. Parakeet had no known direct exposure to product and was in a room separate from where the product was sprayed. Necropsy was never performed to determine cause of death.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews.