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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-3309

2. Registrant Information.

Registrant Reference Number: 794072

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.

26-MAY-11

5. Location of incident.

Country: UNITED STATES

Prov / State: FLORIDA

6. Date incident was first observed.

05-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)

PMRA Registration No.       PMRA Submission No.       EPA Registration No. 1021-1686-68543

Product Name: Bengal Concentrated Roach Flea Fogger 3

  • Active Ingredient(s)
    • CYPHENOTHRIN
      • Guarantee/concentration .4 %
    • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
      • Guarantee/concentration .4 %
    • PRALLETHRIN
      • Guarantee/concentration .03 %

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

Product Name: Magic Coat Shampoo for fleas for cats (unknown manufacturer)

  • Active Ingredient(s)

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

Product Name: non-specific environmental flea spray (unknown manufacturer)

  • Active Ingredient(s)

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: 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 III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Cat / Chat

3. Breed

Domestic Shorthair

4. Number of animals affected

1

5. Sex

Unknown

6. Age (provide a range if necessary )

1.50

7. Weight (provide a range if necessary )

10.00

lbs

8. Route(s) of exposure

Unknown

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

  • General
    • Symptom - Death

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

5/26/2011 Caller reports that he applied the product in the home three weeks ago. Caller also used an unknown flea spray in the home as well and a cat flea shampoo. No known direct exposure to the insecticide was witnessed but he states his cat had free access to the treated areas. The caller has not seen his cat for two days, but people that work near his home told him that they found a dead cat. Based on the description of the dead cat, the caller believes this may be his cat, however, he has not actually seen the deceased cat.


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 product use history is extremely vague and lacks any description of a known or defined point of direct exposure to this product. The course of events in this case are highly speculative. Even had casual or incidental contact with this product occurred, serious illness resulting in death lacks plausibility.