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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-3912

2. Registrant Information.

Registrant Reference Number: 001

Registrant Name (Full Legal Name no abbreviations): United Phosphorus, Inc.

Address: 630 Freedom Business Center, Suite 402

City: King of Prussia

Prov / State: PA

Country: USA

Postal Code: 19406

3. Select the appropriate subform(s) for the incident.


4. Date registrant was first informed of the incident.


5. Location of incident.


Prov / State: CALIFORNIA

6. Date incident was first observed.


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.


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

Product Name:

  • Active Ingredient(s)
      • Guarantee/concentration 57 %

7. b) Type of formulation.


Application Information

8. Product was applied?


9. Application Rate.

10. Site pesticide was applied to (select all that apply).

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?


Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Medical Professional

2. Demographic information of data subject

Sex: Male

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

3. List all symptoms, using the selections below.


  • General
    • Symptom - Death

4. How long did the symptoms last?

Unknown / Inconnu

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


6. a) Was the person hospitalized?


6. b) For how long?


7. Exposure scenario


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

Poisoning from ingestion of the pesticide

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

10. Route(s) of exposure.


11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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.)

On July 22, 2013, at approximately 5:00 pm (Eastern), the US registrant received a call from (name) (phone #) at (name) Hospital in (city), CA, USA informing UPI that the an individual male, aged , ingested tablets or pills from a plastic baggie in his possession, became seriously ill and was taken to the (name) Community Hospital. The (name) County, Coroners office determined that the tablets or pills contained aluminum phosphide. (name) requested information on the proper disposal of the remaining material left in the plastic bag. On the morning on July 23, 2013, the US registrant learned from a press report that the individual had died. The (name) County Coroners office is investigating the incident. The contact at that office is Detective (name) (phone#). The registrant has not been able to determine whether the tablets that the individual ingested were UPIs aluminum phosphide tablets, EPA Reg. No. 70506-13, brandname, Weevilcide.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.

The person had found the baggie and ingested the product. The individual was not involved in the application of the product and the product was not used according to label directions. The report was also submitted pursuant to FIFRA 6(a)(2) and 40 C.F.R. 159.184 to the U.S. Environmental Protection Agency.