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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-0665

2. Registrant Information.

Registrant Reference Number: 541828

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.

01-OCT-09

5. Location of incident.

Country: UNITED STATES

Prov / State: VIRGINIA

6. Date incident was first observed.

30-SEP-09

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. 1021-1599-79529

Product Name: BLACK FLAG FLEA ENDER Room + Pet Spray

  • Active Ingredient(s)
    • PERMETHRIN
      • Guarantee/concentration .05 %
    • PYRETHRINS
      • Guarantee/concentration .056 %

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: Animal / Usage sur un animal domestique

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?

No

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

1

5. Sex

Male

6. Age (provide a range if necessary )

0.15

7. Weight (provide a range if necessary )

4

lbs

8. Route(s) of exposure

Skin

9. What was the length of exposure?

<=15 min / <=15 min

10. Time between exposure and onset of symptoms

>8 hrs <=24 hrs / > 8 h < = 24 h

11. List all symptoms

System

  • Gastrointestinal System
    • Symptom - Vomiting
  • General
    • Symptom - Death
  • Nervous and Muscular Systems
    • Symptom - Ataxia

12. How long did the symptoms last?

Persisted until death

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

Yes

14. a) Was the animal hospitalized?

Yes

14. b) How long was the animal hospitalized?

1

Day(s) / Jour(s)

15. Outcome of the incident

Died

16. How was the animal exposed?

Treatment / Traitement

17. Provide any additional details about the incident

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

10/1/2009 Product was applied to the dog 24 hours ago. This morning the dog was found to be ataxic. The dog has vomited several times tonight. 10/17/2009 Callback attempted to the original caller. A message was left requesting follow up information. 10/29/2009 Callback to the original caller for follow up. The dog was taken to a veterinarian. The dog was bathed, given antibiotics, and had several other unknown treatments performed. The dog died at the clinic on 10/1/2009. A necropsy was performed, but the results were inconclusive.


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. Given the very young age of this patient many potential etiologies must be considered for this type of illness. Pyrethroid toxicity typically manifests in the form of gross tremors in a dog which was not reported in this case. Furthermore, such toxicity would be unexpected given the low concentrations of pesticide in this product. Finally, this product has label instructions stating that it should not be used on pets less than 12 weeks of age. The owner disregarded these instructions resulting in the misuse of this product on an 8 week old dog.