Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-4492

2. Registrant Information.

Registrant Reference Number: 834775

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.

09-AUG-11

5. Location of incident.

Country: UNITED STATES

Prov / State: LOUISIANA

6. Date incident was first observed.

09-AUG-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)

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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 %

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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: Pub. Area - Indoor/Zone publique - int

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.

Other

2. Demographic information of data subject

Sex: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Skin
  • Symptom - Burns (2nd or 3rd degree)

4. How long did the symptoms last?

Anticip. permanent/Permanence anticipée

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

Occupational

8. How did exposure occur? (Select all that apply)

Application

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?

<=15 min / <=15 min

12. Time between exposure and onset of symptoms.

<=30 min / <=30 min

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.)

Notification of this incident was received by the manufacturer on August 9, 2011 from an attorney representing the consumer. On September 26, 2009, the consumer apparently used a product manufactured and distributed by Black Flag. She apparently used 'Black Flag Flea Ender' at her veterinary office. As she applied her clothing. Several minutes after she finished applying the product, she walked into another area to light a cigarette. Immediately, the remnants of the airborne aerosol surrounding her person flamed and caused her shirt to catch fire. As a result, she was severely injured and sustained third degree burns and disfiguring and disabling features on her torso. At all material times, she was apparently using the product in a safe and reasonably anticipated use.

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.