Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2008-4590

2. Registrant Information.

Registrant Reference Number: 369268

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.

28-AUG-08

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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 1021-1608-79529

Product Name: BLACK FLAG Kills Ants Roaches Spiders Formula 19

• Active Ingredient(s)
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • Guarantee/concentration .25 %
  • PERMETHRIN
    • Guarantee/concentration .2 %
  • PYRETHRINS
    • Guarantee/concentration .05 %

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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).

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

Rat Terrier

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

0.58

7. Weight (provide a range if necessary )

1.5

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Anorexia
  • Symptom - Bloody stool
  • Symptom - Vomiting

• General
  • Symptom - Death
  • Symptom - Lethargy

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 Defined point of exposure not evident or witnessed. Exposure based on speculation.

17. Provide any additional details about the incident

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

8/28/2008 Caller reports that the product was applied 3 or 4 days ago. Caller's dog stopped eating yesterday, and today is lethargic, vomiting, and has blood in the feces. Dog did not have any witnessed direct exposure to product. 9/13/2008 Callback attempted to original caller. A message was left requesting follow up information. 9/18/2008 Callback to original caller for follow up information. Caller reports that the dog died at home, and that no treatments were performed. Cause of death was not definitively determined however, when the owner called a veterinarian the veterinarian surmised that the dog is likely suffering from Parvo virus given its young age and lack of adequate preventative veterinary care.

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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. Any relationship between the use of this product and development of a severe and fatal illness is inconceivable and lacks and biological plausibility. Secondly, the product use history is extremely vague and lacks any description of a known or defined point of direct exposure to this product. Even had the dog ingested material that had been sprayed with this insecticide, an active concentration of permethrin of 0.20% and a pyrethrin concentration of 0.05% would not be expected to lead to fatal illness, especially given that their are flea adulticide products on the market for direct application to dogs that contain permethrin concentrations greater than 100X higher than in this particular insecticide. Thirdly, a medical evaluation by a licensed veterinarian in order to determine the cause of the illness was never sought.