Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2018-2007
2. Registrant Information.
Registrant Reference Number: 2168922
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.
08-JAN-18
5. Location of incident.
Country: UNITED STATES
Prov / State: WEST VIRGINIA
6. Date incident was first observed.
08-JAN-18
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. 1021-1674-8845
Product Name: Hot Shot Bedbug & Flea Fogger
- Active Ingredient(s)
- N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
- Guarantee/concentration .16 %
- PIPERONYL BUTOXIDE
- Guarantee/concentration .1 %
- PYRETHRINS
- Guarantee/concentration .05 %
- PYRIPROXYFEN
- Guarantee/concentration .1 %
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 III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Unknown
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
60.00
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 <=2 hrs / >30 min <=2 h
11. List all symptoms
System
- Nervous and Muscular Systems
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
4/27/2018 A report dated 1/8/2018 was forwarded for documentation. The report states that caller reports applying the fogger 1 week ago, and may have also used the spray but caller cannot confirm this. Caller's dog went downstairs 90 minutes ago and chewed on something. The dog began having seizures, and died while caller was on the line.
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.