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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-2263

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.


4. Date registrant was first informed of the incident.


5. Location of incident.


Prov / State: FLORIDA

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

Product Name: VIKANE

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

7. b) Type of formulation.

Other (specify)


Application Information

8. Product was applied?


9. Application Rate.


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).

Feedback from local EPA was that the Fume Log indicated "the job was done correctly."

To be determined by Registrant

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


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

1. Source of Report.


2. Demographic information of data subject

Sex: Unknown

Age: <=1 yr / < = 1 an

3. List all symptoms, using the selections below.


  • 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.


6. a) Was the person hospitalized?


6. b) For how long?

7. Exposure scenario


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

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


10. Route(s) of exposure.


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 the 7th of June, 2018, x out of x was alerted to an alleged incident at a multi-unit structure that was fumigated this week in x. The 8 unit structure was fumigated on Monday, June 4th, Aeration began on Tuesday June 5th and the final clearance was conducted mid-day on Wednesday June 6th. A x old infant was dropped off at a bottom floor unit sometime in the earlier AM on June 7th and was found deceased inside the unit late morning. Early morning of June 7th, the tenant of mentioned unit, picked up multiple baby mattresses from the property management office. The mattresses had been removed from the unit prior to the fumigation. The property management office signed an avadavat for the police, stating the mattresses were removed from the fumigated space and were picked up this AM by the tenant. FL Dept of Ag and Consumer Services (FDACS) was contacted immediately and had 3 inspectors on site throughout the day. FDACS contacted another local fumigator, to perform an independent 3rd party clearance check and 0 ppm of Vikane were reported in the 7 available units that were not roped off. Douglas worked with FDACS to have them contact the investigating officer, in an effort to minimize the situation. FDACS has also contacted the Department of Health. UPDATE: JUNE 18TH Dacs department stated that officially the local EPA office in x closed their investigation last Thursday. They aren't suspecting any wrong doing by the fumigator. As well their Fume log looked as if the job was done correctly. Unofficially, the police are still looking into the persons tending to the child.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.