Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-1461

2. Registrant Information.

Registrant Reference Number: 041008

Registrant Name (Full Legal Name no abbreviations): Liphatech, Incorporated

Address: 3600 West Elm Street

City: Milwaukee

Prov / State: WI

Country: USA

Postal Code: 53074

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

09-APR-08

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

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)

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

Product Name: Just One Bite

• Active Ingredient(s)
  • BROMADIOLONE
    • Unknown

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

Product Name: Unknown

• Active Ingredient(s)
  • BRODIFACOUM
    • Unknown

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7. b) Type of formulation.

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: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Blood
  • Symptom - Bleeding

• Liver
  • Symptom - Hepatic failure
  • Specify - cirrhosis

• General
  • Symptom - Death

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

1

Day(s) / Jour(s)

7. Exposure scenario

Non-occupational

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

Other

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?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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.)

Autopsy results showed that bromadiolone was present in the blood at 0.61 mg and brodifacuom at 0.034 mg-I coudn't ascertain if the units were mg/dL or something else. The autopsy also showed cirrhosis of the liver although the victim was not an alcoholic. The victim was taking unidentified medication that had been received from (country) and the detective was having the medication analyzed. The victim had also had her thyroid removed in (country) in the last year or so. The victim had been reportedly suffering from cold and flu-like symptoms for approximately one year. She was hospitalized for vomiting blood and bleeding from the rectum but died the next day.

To be determined by Registrant

14. Severity classification.

Death

15. Provide supplemental information here.

I became aware of this incident on Wednesday, April 8, 2008 at 4:30pm when Detective (name) of the (location) Sheriff's office contacted me looking for information about the effects of bromadiolone and brodifacuom. He was investigating case # in which a woman died they were trying to ascertain how these products ended up in the woman's bloodstream. He verified that Just One Bite bromadiolone 1# blocks had been used in the woman's home sometime within the past 2 years. We have not manufactured this product since December of 2006 and do not manufacture any brodifacuom products so I am not sure of A.I. percentages, registration numbers or product brand names.