Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-5673
2. Registrant Information.
Registrant Reference Number: 816677
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.
08-JUL-11
5. Location of incident.
Country: UNITED STATES
Prov / State: CALIFORNIA
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. 1021-1855-79529
Product Name: BLACK FLAG MATA hormigas ants cucarachas roaches aranas spiders killer
- Active Ingredient(s)
- CYPERMETHRIN
- Guarantee/concentration .03 %
- PRALLETHRIN
- Guarantee/concentration .011 %
- PYRETHRINS
- Guarantee/concentration .011 %
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. - Out Home / Rés - à l'ext.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?
No
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Fish / Poisson
3. Breed
Freshwater Fish
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Skin
9. What was the length of exposure?
>3 days <=1 wk / >3 jours <=1 sem
10. Time between exposure and onset of symptoms
>3 days <=1 wk / >3 jours <=1 sem
11. List all symptoms
System
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 Product missapplied near fish pond
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
July 8, 2011 Consumer reports that this pesticide was sprayed directly on the filtering apparatus used to filter the water of a koi fish pond on July 3. Six of her pet koi fish were found dead on July 8. The three remaining live fish have been moved to another pond.
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. Pyrethrins and pyrethroid based pesticided are known to be toxic to fish. This product had be grossly misused resulting in the death in pet koi fish.