Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-2914

2. Registrant Information.

Registrant Reference Number: 2270570

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.

Human

4. Date registrant was first informed of the incident.

13-JUL-18

5. Location of incident.

Country: UNITED STATES

Prov / State: PENNSYLVANIA

6. Date incident was first observed.

12-JUL-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: HS BED BUG & FLEA KILLER FOGGER 3-2 OZ

• Active Ingredient(s)
  • ESFENVALERATE
    • Guarantee/concentration .1 %
  • 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?

No

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

1. Source of Report.

Medical Professional

2. Demographic information of data subject

Sex: Female

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Death

• Cardiovascular System
  • Symptom - Cardiac arrest

4. How long did the symptoms last?

Persisted until death

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

Unknown

6. a) Was the person hospitalized?

No

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

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

What was the activity? Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding the activity

Drift from the application site

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

Unknown

10. Route(s) of exposure.

Respiratory

11. What was the length of exposure?

<=15 min / <=15 min

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.)

7/13/2018 A report dated 7/10/2018 was forwarded for documentation. The report states that caller is from the coroner's office calling to report that product was used by an individual last night. The individual set off the product forgetting that their grandmother was in the other bedroom. The grandmother is now deceased from cardiac arrest. The individual has used foggers in the past and put a towel under the door. This time there was a hole in the door and product was able to drift into the bedroom. The grandmother was a smoker and had several lung issues including chronic obstructive pulmonary disease and emphysema.

To be determined by Registrant

14. Severity classification.

Death

15. Provide supplemental information here.

AThe product use history is somewhat vague in that it lacks a well documented description of a known or defined point of direct exposure to this product. In most cases of casual or incidental contact with this product death would not be an expected and is not consistent with the toxicological profile of this product. Given this patients very significant underlying medical history there is a at least a theoretical risk of development of significant respiratory symptoms secondary to over-exposure to any substance that can significantly alter the air quality in the room in which she resided. 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.