Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-5745

2. Registrant Information.

Registrant Reference Number: 1441149

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.

10-AUG-14

5. Location of incident.

Country: UNITED STATES

Prov / State: TEXAS

6. Date incident was first observed.

10-AUG-14

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. 1021-1866-53853

Product Name: Black Flag Fogging Insecticide Formula 2

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

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7. b) Type of formulation.

Other (specify)

Aerosol

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 III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Cat / Chat

3. Breed

DSH

4. Number of animals affected

1

5. Sex

Male

6. Age (provide a range if necessary )

4

7. Weight (provide a range if necessary )

8.00

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

<=30 min / <=30 min

11. List all symptoms

System

• General
  • Symptom - Death

• Nervous and Muscular Systems
  • Symptom - Agitation

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

8/10/2014 Caller states that he was fogging his backyard about 2 hours ago, and saw his cat come around the corner of the area where the fogging was taking place. Caller immediately took the cat inside, and no direct exposure was witnessed. As he put the cat in the house and out of the area that he was treating, he noticed that the cat seemed extremely frightened. When he went back in the house after spraying, he found the cat deceased on the floor. The cat was never evaluated by a DVM for necropsy to determine cause of death.

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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 resultant feline fatality reported in this case is inconceivable and lacks biological plausibility. The product use history lacks any description of a known or defined point of direct exposure to this product. Even had casual or incidental contact with this pesticide occurred, a fatal outcome as reported in this cat is unexpected. Even if true pyrethroid toxicity were to occur in this case it would manifest with acute neurological complications, primarily in the form of tremors, seizures and ataxia which were not reported in this incident. Finally, a necropsy was not performed on the expired animal in order to determine a cause of death.