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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-0810

2. Registrant Information.

Registrant Reference Number: 2121183

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.


5. Location of incident.


Prov / State: ILLINOIS

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. 1021-1866-53853

Product Name: Black Flag Fogging Insecticide Formula 2

  • Active Ingredient(s)
      • Guarantee/concentration .15 %
      • Guarantee/concentration .15 %

7. b) Type of formulation.

Application Information

8. Product was applied?


9. Application Rate.


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

Site: Res. - Out Home / Rés - à l'

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?


Subform III: Domestic Animal Incident Report

1. Source of Report

Animal's Owner

2. Type of animal affected

Dog / Chien

3. Breed

Labrador Retriever

4. Number of animals affected


5. Sex


6. Age (provide a range if necessary )


7. Weight (provide a range if necessary )



8. Route(s) of exposure



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


  • Gastrointestinal System
    • Symptom - Vomiting
  • General
    • Symptom - Death
  • Nervous and Muscular Systems
    • Symptom - Muscle weakness
    • Symptom - Difficulty getting up
  • Respiratory System
    • Symptom - Shortness of breath
  • Nervous and Muscular Systems
    • Symptom - Collapse

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.


14. a) Was the animal hospitalized?


14. b) How long was the animal hospitalized?


15. Outcome of the incident


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

10/5/2017 Caller reports that on 9/3/2017 someone on her neighbor's property was using the product in the yard. Caller's dog was tied out on a leash in caller's backyard. The dog barked, and caller looked outside. Caller saw 3 billows of the fog drift from the neighbor's property directly towards her dog. Caller tried to call the dog inside, and it took a minute or two to for the dog to decide to come towards the house. As he started to walk towards the house, the dog collapsed in the yard. he was able to get back up and get inside the house. Once inside, he vomited multiple times and was very weak. He collapsed again inside the house within 45 minutes. The dog was unable to get up again. He had shortness of breath at times, and kept trying to stand but was too weak. He urinated in place several times. The pet died the following day 9/4/2017 in the afternoon. Caller did offer the dog food and water, but did not administer any specific treatments. Caller spoke to the veterinarian over the phone on the morning of 9/4/2017, but did not take the dog to the veterinarian before he died. Caller does not have access to the product. She looked at the label after the incident and noted the name only. Caller's neighbor was not the one applying the product, but it was a friend of the neighbor. The dog was previously healthy and was current on vaccines. The veterinarian said the dog was overweight and was on a diet. 10/7/2017 Caller contacted her neighbor and was able to obtain product information from the can reported to have been used the day of the exposure. Owner reports that product was sprayed multiple days.

To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification


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.