Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-0634

2. Registrant Information.

Registrant Reference Number: 1274223

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.

30-OCT-13

5. Location of incident.

Country: UNITED STATES

Prov / State: SOUTH CAROLINA

6. Date incident was first observed.

21-OCT-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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 1021-1698-3487

Product Name: Eagles 7 Spray Kill

• Active Ingredient(s)
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • Guarantee/concentration .239 %
  • PERMETHRIN
    • Guarantee/concentration .2 %
  • PYRETHRINS
    • Guarantee/concentration .05 %
  • PYRIPROXYFEN
    • Guarantee/concentration .02 %

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

Product Name: Raid Bomb

• Active Ingredient(s)

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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

Jack Russell Terrier

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 )

5.00

lbs

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

>3 days <=1 wk / >3 jours <=1 sem

11. List all symptoms

System

• Gastrointestinal System
  • Symptom - Anorexia
  • Symptom - Bloody stool
  • Symptom - Vomiting

• General
  • Symptom - Death

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?

Unknown

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

10/30/2013 Caller states the product was used in her home on 10/21/13 and her dog was kept out of the area and in a different room for 3 days. The caller states she did not witness any exposure but is concerned the dog may have ingested a roach that was affected by the product. The caller states the dog became anorexic on 10/27/13. The dog developed vomiting and blood from the rectum on 10/28/13. Caller spoke to the veterinarian over the phone who believed the dog may have had Parvo, but she did not bring the dog in for evaluation due to financial concerns. Caller administered Pedialyte and milk at home. The dog passed away yesterday morning. The dog had been previously vaccinated for Parvo. The caller states there was a 'Raid Bomb' used in the home as well, but the dog was not in the area when the product was set off. She does not have identifying information for this Raid brand product.

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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. Any relationship between the use of this product and the development of the complications reported in this case is inconceivable and lacks biological plausibility. Secondly, the product use history is extremely vague and lacks any description of a known or defined point of direct exposure to this product. Even had casual or incidental contact with a surface treated with this pesticide occurred, such serious illness as reported in this dog is unexpected. Furthermore, this animal was never properly evaluated and treated by a veterinarian, nor had it received proper preventive care in the form of vaccines and anti-parasite treatment prior to the occurrence of this incident.