Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-3307

2. Registrant Information.

Registrant Reference Number: 785940

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.

09-MAY-11

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

6. Date incident was first observed.

08-MAY-11

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. 1021-1742-73992

Product Name: COOPER'S DROP DEAD FLEA + TICK KILLER

• Active Ingredient(s)
  • PERMETHRIN
    • Guarantee/concentration .25 %

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7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

No

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 III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

German Shepherd

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 )

15.00

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

<=15 min / <=15 min

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Bloody vomit
  • Symptom - Vomiting

• General
  • Symptom - Death
  • Symptom - Lethargy

• 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?

No

14. b) How long was the animal hospitalized?

15. Outcome of the incident

Died

16. How was the animal exposed?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

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

5/9/2011 Caller returned home yesterday and found that the dog had chewed on the aerosol can. The dog appeared to be ataxic and drowsy at the time. The dog was taken to the veterinarian at that time. The dog was given an unspecified medication injection and oral medication and sent home. Today the dog does not seem to have improved, and may have vomited blood today. 6/8/2011 Callback to the original caller for follow up information. The dog died one week after the initial evaluation by the veterinarian. The dog was under observation at the veterinarian when it died suddenly.

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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. Although the ingestion of this pesticide formulation my cause some gastrointestinal distress, such symptoms are typically of minor severity and transient in nature. They are not typically associated with major illness and death. Serious systemic pyrethroid toxicity it typically associated with significant muscle tremors or seizure, neither which were reported in this case, nor would they be expected with a concentration of just 0.25% permethrin. It is conceivable that if the animal ingested the physical packaging, significant gastrointestinal injury or obstruction may occur.