Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-2360

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.

04-MAY-18

5. Location of incident.

Country: UNITED STATES

Prov / State: CALIFORNIA

6. Date incident was first observed.

02-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).

County authorities re-certified the structure and stated that it was cleared properly.

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: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Unconsciousness

• Gastrointestinal System
  • Symptom - Vomiting

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?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

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)

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.)

Caller is reporting AE. Her home was treated with product on 4/30 and they returned on 5/2. Her husband began vomiting around 11:30 PM and Sx continued throughout the night. They went to ER yesterday and he was admitted. Caller was then told that her husband was 'not responding properly' so they performed CT scan - determined no stroke, also had spinal tap - waiting on results. He will have MRI today. He is currently still in hospital and now unconscious. Caller has contacted PCO to return and assess home but they have not yet done so. She was currently on her way to hospital and did not have any other product information besides name available at this time.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

Tenant was a part of a multi-unit fumigation that was cleared last Wednesday. The male tenant's wife called x County and the county re-certified the structure and stated that it was cleared properly. Contact person stated that he was not aware of any other tenant in the building showing any symptoms and that the male tenant in question has had serious health problems in the past.