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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2013-4473

2. Registrant Information.

Registrant Reference Number: 1188651

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.

18-JUN-13

5. Location of incident.

Country: UNITED STATES

Prov / State: COLORADO

6. Date incident was first observed.

04-JUN-13

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. 1021-1691

Product Name: EVERCIDE CRAWLING INSECT KILLER 2548

  • Active Ingredient(s)
    • ESFENVALERATE
      • Guarantee/concentration .05 %
    • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
      • Guarantee/concentration .3 %
    • PRALLETHRIN
      • Guarantee/concentration .03 %

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: Agricultural-Indoor / Agricole-intérieur

Préciser le type: Greenhouse

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

6

5. Sex

Unknown

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Unknown

9. What was the length of exposure?

<=15 min / <=15 min

10. Time between exposure and onset of symptoms

>1 wk <=1 mo / > 1 sem < = 1 mois

11. List all symptoms

System

  • General
    • Symptom - Death
  • Respiratory System
    • Symptom - Shortness of breath

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?

Spray drift / Dérive de pulvérisation

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

6/18/2013 Caller sprayed product 2 weeks ago in a greenhouse to kill spiders. She admits to spraying around a pond where she keeps pet fish. Caller did not realize she needed to cover the fish pond that is in the greenhouse. There are 6 fish in the pond, and one died today. The other 5 fish are staying close to the surface more than normal and appear to be ill. 6/26/2013 Callback to the original caller for follow up information. Caller states that 5 of the 6 fish have died, and she is not sure if the 6th fish will live. She is not going to clean the 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. Product has been misused by the consumer. The instructions on the container clearly state that this product is toxic to fish and most not be used near fish bearing sources of water.