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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2018-4274

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).

Site was a residential home converted into a small business office.

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: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.


  • General
    • Symptom - 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.)

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.

Date: August 31, 2018 at 10:27:32 EDT Email notification to Douglas Products employee Please consider this e-mail correspondence as XXX PEST CONTROL, INC. notification of a potential fumigation death at XXX, XXX Florida. Law enforcement has been notified and the Owner and me are enroute to the scene. I have requested all records associated with the service. ***** Date: September 10, 2018 3:11 PM Email notification to Douglas Products employee containing narrative of the investigation. Narrative report dated: 9/10/2018. INTRODUCTION This for-cause alleged Use/Misuse investigation was conducted pursuant to the authority of the Florida Pest Control Law, F. S. 482, and the Federal Pesticide Law, FIFRA, in response to a written directive to investigate an allegation the Department received of an alleged exposure death at a fumigation conducted by XXX Pest Control at an office located atXXX, XXX, Fl XXX. CASE REVIEW/SUMMARY A human death occurred at XXX, XXX, Fl XXX while the structure was under fumigation. The death appears to be related to the fumigation of the structure on 8/30/2018 by XXX Pest Control. It appears that pesticides were applied per label directions, and that the death which occurred was accidental. BACKGROUND I have conducted numerous fumigation inspections on XXX Pest Control over the past 2 years. No violations have been noted as a result of any of these inspections. (Name) Environmental Specialist II.