Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2012-1827

2. Registrant Information.

Registrant Reference Number: 965523

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

Packaging Failure

4. Date registrant was first informed of the incident.

27-APR-12

5. Location of incident.

Country: UNITED STATES

Prov / State: TEXAS

6. Date incident was first observed.

24-APR-12

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. 1021-1866-53853

Product Name: Black Flag Fogging Insecticide Formula 2

• Active Ingredient(s)
  • D-PHENOTHRIN
    • Guarantee/concentration .15 %
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration .15 %

---

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

Product Name: Black Flag Propane Powered Insect Fogger Machine

• Active Ingredient(s)
  • DEVICE, NO GUARANTEE REQUIRED

---

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?

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: Male

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

3. List all symptoms, using the selections below.

System

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

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

2

Day(s) / Jour(s)

7. Exposure scenario

Non-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.

Skin

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.)

April 27, 2012 Caller states that he was using the propane powered fogging machine in his back yard 3 days ago when the apparatus somehow malfunctioned resulting in flames bursting out around the fogging apparatus and up his right hand and arm. The apparatus consists of a reservoir containing the liquid insecticide that is attached to a hand held device that is also attached to a mini portable propane tank. He is not able to elucidate any further on how exactly the flame from the propane torched ended up spreading out from the heating elements and up his arm. He was immediately transferred to a local hospital where he was admitted and hospitalized for 2 days. He was diagnosed with and treated for 3rd degree burns. The caller was reluctant to go into details regarding the extent of treatment.

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. Extent of injury appears to be directly attributed to the propane powered heating element and not the actual insecticide.

Subform VI: Packaging Failure

1. What is the type of packaging that failed?

Other / Autre

specify Black Flag Propane Powered Insect Fogger Machine

2. Did packaging failure occur during?

Use of Product

3. Did packaging failure result in?

potential injury

4. Describe how the packaging failed and the surrounding circumstances, including a description of the potential injury or exposure.

April 27, 2012 Caller states that he was using the propane powered fogging machine in his back yard 3 days ago when the apparatus somehow malfunctioned resulting in flames bursting out around the fogging apparatus and up his right hand and arm. The apparatus consists of a reservoir containing the liquid insecticide that is attached to a hand held device that is also attached to a mini portable propane tank. He is not able to elucidate any further on how exactly the flame from the propane torched ended up spreading out from the heating elements and up his arm. He was immediately transferred to a local hospital where he was admitted and hospitalized for 2 days. He was diagnosed with and treated for 3rd degree burns. The caller was reluctant to go into details regarding the extent of treatment.

For Registrant use only

5. 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. Extent of injury appears to be directly attributed to the propane powered heating element and not the actual insecticide.