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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-5820

2. Registrant Information.

Registrant Reference Number: 694268

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.

18-SEP-10

5. Location of incident.

Country: UNITED STATES

Prov / State: NEBRASKA

6. Date incident was first observed.

16-SEP-10

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?

Yes

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Chihuahua

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

1.50

7. Weight (provide a range if necessary )

4.00

lbs

8. Route(s) of exposure

Skin

Oral

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 - 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?

Treatment / Traitement

17. Provide any additional details about the incident

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

9/18/2010 Caller's dog was sprayed with the product two days ago. The dog licked herself afterwards. The dog developed vomiting yesterday, which worsened overnight. The dog has been lethargic and anorexic today, and has developed bleeding from the rectum. 10/7/2010 Callback to the original caller for follow up information. The dog was not brought to the veterinarian as caller could not afford treatment. The dog died later that night. Caller's other dog developed symptoms caused by parvovirus, and caller believes the dog that died may also have had parvovirus, but this could not be confirmed by the veterinarian.


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. The active ingredients in this flea product are not at concentrations high enough to produce the profound illness reported even if a treated dog were to lick the residues off the fur. Secondly, the firm diagnosis of Parvo virus in the second puppy from the same litter rules out any involvement of the pesticide in the illnesses of these two puppies from the same litter.

Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Chihuahua

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

1.50

7. Weight (provide a range if necessary )

4.00

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 - Anorexia
    • Symptom - Vomiting
  • General
    • Symptom - Lethargy

12. How long did the symptoms last?

>3 days <=1 wk / >3 jours <=1 sem

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

Fully Recovered / Complètement rétabli

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

9/18/2010 Caller's dog was sprayed with the product two days ago. The dog licked herself afterwards. The dog developed vomiting yesterday, which worsened overnight. The dog has been lethargic and anorexic today, and has developed bleeding from the rectum. 10/7/2010 Callback to the original caller for follow up information. The dog was not brought to the veterinarian as caller could not afford treatment. The dog died later that night. Caller's other dog developed symptoms caused by parvovirus, and caller believes the dog that died may also have had parvovirus, but this could not be confirmed by the veterinarian.


To be determined by Registrant

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

Moderate

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. The active ingredients in this flea product are not at concentrations high enough to produce the profound illness reported even if a treated dog were to lick the residues off the fur. Secondly, the firm diagnosis of Parvo virus in the second puppy from the same litter rules out any involvement of the pesticide in the illnesses of these two puppies from the same litter.