Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2015-3326

2. Registrant Information.

Registrant Reference Number: 1620277

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.

Human

4. Date registrant was first informed of the incident.

03-JUN-15

5. Location of incident.

Country: UNITED STATES

Prov / State: LOUISIANA

6. Date incident was first observed.

03-JUN-15

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. 1021-1674-8845

Product Name: Hot Shot Bedbug & Flea Fogger

• Active Ingredient(s)
  • ESFENVALERATE
    • Guarantee/concentration .1 %
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • Guarantee/concentration .16 %
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration .1 %
  • PYRETHRINS
    • Guarantee/concentration .05 %
  • PYRIPROXYFEN
    • Guarantee/concentration .1 %

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7. b) Type of formulation.

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

1. Source of Report.

Medical Professional

2. Demographic information of data subject

Sex: Female

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

3. List all symptoms, using the selections below.

System

• Cardiovascular System
  • Symptom - Cardiac arrest

• Gastrointestinal System
  • Symptom - Vomiting

• Nervous and Muscular Systems
  • Symptom - Coma

• Respiratory System
  • Symptom - Apnea

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

No

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

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

Application

What was the activity? Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding the activity

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

None

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

<=15 min / <=15 min

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.)

A report originally dated June 3, 2015 was forwarded to MGK for documentation by a third party. The report states that the patient used the product in her home and subsequently developed respiratory distress and vomiting. The patient was found by family and presented to the ED unresponsive, pulse less and apneic. While at the ED CPR was performed and the patient was intubated and placed on a ventilator. No follow up was performed and the patient disposition is unknown.

To be determined by Registrant

14. Severity classification.

Major

15. 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 signs and symptoms reported in this case are not consistent with the known toxicology of the material involved at the concentrations used in this spray, even following the type of accidental exposure as reported in this case. If a subject accidentally inhales airborne spray, upper respiratory irritation and coughing my occur, however, such symptoms are typically transitory in nature and do not devolve into serious cardiorespiratory compromise. The details regarding product use and the nature of this patient's exposure remain unclear, as does additional medical follow-up that may provide more insight to the causative nature of this patient's illness.