Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-2902

2. Registrant Information.

Registrant Reference Number: 1125133

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.

25-FEB-13

5. Location of incident.

Country: UNITED STATES

Prov / State: TEXAS

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)

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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 .38 %
  • PRALLETHRIN
    • Guarantee/concentration .03 %

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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

Dog / Chien

3. Breed

Boxer

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 )

40.00

lbs

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• General
  • Symptom - Death
  • Symptom - Parvovirus infection

• Nervous and Muscular Systems
  • Symptom - Difficulty getting up

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

2/25/2013 Caller used 4 cans of the product in the home yesterday. Caller kept all of his animals out of the home for several hours after the product was used. This afternoon, caller returned home to find one of the dogs unable to get up off of the floor. The other dogs are asymptomatic. 3/1/2013 Callback to the original caller for follow up. The dog died at home before he could get to the veterinarian. Caller brought the body to the veterinarian, and was told she died from Parvo virus.

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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. The toxicological profile of this pesticide formulation is such that even if the animal had incidental contact with residue on a surface, fatal toxicity would not be expected. Furthermore, the cause of this dog's death was confirmed as Parvo virus by a veterinarian.