Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-2146

2. Registrant Information.

Registrant Reference Number: 28240

Registrant Name (Full Legal Name no abbreviations): Douglas Products and Packaging Company, LLC

Address: 1550 East Old 210 Hwy

City: Liberty

Prov / State: MO

Country: The United States of America

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

16-MAY-18

5. Location of incident.

Country: UNITED STATES

Prov / State: FLORIDA

6. Date incident was first observed.

16-MAY-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)

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PMRA Registration No. 28240      PMRA Submission No.       EPA Registration No. 1015-78

Product Name: VIKANE

• Active Ingredient(s)
  • SULFURYL FLUORIDE
    • Guarantee/concentration 99.8 %

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7. b) Type of formulation.

Other (specify)

Fumigant

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).

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Unknown
  • Symptom - Other
  • Specify - Death

4. How long did the symptoms last?

Persisted until death

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

No

6. a) Was the person hospitalized?

No

6. b) For how long?

7. Exposure scenario

Non-occupational

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

Contact with treated area

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.

Unknown

11. What was the length of exposure?

Unknown / Inconnu

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.)

On 16 of May, 2018, at aprox. 4:20 pm , the owners of x called to report that one of their fumigation crews had returned to initiate aeration procedure at the above address, a rehabilitation residence/ adult boarding center, and discovered an unidentified male inside the secured structure deceased. According to the owners, there was evidence of tarp clamps and a warning sign at a " false seam" removed from the tarp and on the ground, in addition, the ground seal had been tampered with and tarps had been pulled away from under the seal. Since the "false seam" is not a union of two tarp sections, it is believed that the victim may have crawled under the tarp after he discovered this was blocked. As the crew began to open the seams on the tarps, the fumigator while wearing a Self-Contained Breathing Apparatus, entered the tarped entrance and accessed the door handle mounted lock box to retrieve the key to the front door. Upon unlocking the door and entering, the fumigator heard what he thought was a radio coming from the left side of the structure. Upon investigating the sound, the fumigator saw a television was on, and behind a curtain partition in one of the rooms, the body of the deceased was found laying on a bed. The fumigator exited the structure, alerted his crew to suspend all activities called 911 and contacted his business office/ owners of x . The Police and Fire Department/ responded, and after being informed about the fumigant and warning agent, the FD donned their PPE,, entered the structure, and asked the crew to remove the two tarps off the structure while the responders opened the remaining doors and windows, preparing to remove the body. There is evidence that a window that had been left partially opened for equilibrium, had the screen removed and was found completely opened. The Florida Department of Agriculture and Consumer Services was also notified and on May 17, their field inspector followed up with obtaining a statement taken from the owner of the compnay. x Sheriff's Office, Detective, x investigated and issued case number x, Medical Examiner case x. On May 24, I was contacted by the owner, to inform me that the Detective had located video survaillance evidence that placed the victim at a local convenience store during the time of the fumigation, and again later, between 6:15 to 7:10pm, after the fumigant had been introduced at aproximately 6:30pm, verifying that the victim was not inside structure at the time of introduction. There was also video discovered that captured the fumigation truck leaving the area at aproximately 7:07pm on May 15.

To be determined by Registrant

14. Severity classification.

Death

15. Provide supplemental information here.