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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-2115

2. Registrant Information.

Registrant Reference Number: 771579

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.

Human

4. Date registrant was first informed of the incident.

05-APR-11

5. Location of incident.

Country: UNITED STATES

Prov / State: FLORIDA

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)

PMRA Registration No.       PMRA Submission No.       EPA Registration No. 1021-1855

Product Name: Black Flag Ant, Roach and Spider Killer

  • Active Ingredient(s)
    • CYPERMETHRIN
      • Guarantee/concentration .03 %
    • PRALLETHRIN
      • Guarantee/concentration .011 %
    • PYRETHRINS
      • Guarantee/concentration .011 %

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

Product Name: Other unspecified insecticides

  • Active Ingredient(s)

7. b) Type of formulation.

Other (specify)

Aerosol

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 II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Female

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

  • Blood
    • Symptom - Bleeding
  • Gastrointestinal System
    • Symptom - Stomach pain
  • Reproductive System
    • Symptom - Miscarriage

4. How long did the symptoms last?

Unknown / Inconnu

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

No

6. a) Was the person hospitalized?

No

6. b) For how long?

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)

None

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.)

April 5, 2011 Caller reports that she used the product once outdoors to kill a wasp 2-3 months ago. She does not recall any known exposure to the product with use. Caller then stated that she had a miscarriage with bleeding and "major stomach pain" in the past month. She was seen by her OBGYN and reportedly found to have vaygon/propoxur level of 0.65 in her blood. She did not require any specific treatments. Other pesticides have been sporadically used in/around her house, including those used by a professional pest control company that treated the house last summer. Caller suspects that her stepdaughter, who recently moved in, has been somehow poisoning her with chemicals. Caller admits that she smokes even though she has asthma. She also claims to have allergies to everything in the environment as well as penicillin.

To be determined by Registrant

14. Severity classification.

Major

15. 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 the delayed development of the complications reported in this case is inconceivable and lacks and biological plausibility. The differential diagnosis for a spontaneous miscarriage is extensive. Furthermore, there is not indication that significant exposure to this product has occurred. The product registration described by the reporter does not contain "Vaygon/Propoxur".