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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-6536

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

Postal Code: 64068

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

Domestic Animal

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).

To be determined by Registrant

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


Subform III: Domestic Animal Incident Report

1. Source of Report


2. Type of animal affected

Cat / Chat

3. Breed


4. Number of animals affected


5. Sex


6. Age (provide a range if necessary )


7. Weight (provide a range if necessary )


8. Route(s) of exposure


9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms


  • General
    • Symptom - Death

12. How long did the symptoms last?

Persisted until death

13. Was medical treatment provided? Provide details in question 17.


14. a) Was the animal hospitalized?


14. b) How long was the animal hospitalized?

15. Outcome of the incident


16. How was the animal exposed?

Contact treat.area/Contact surf. traitée

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

Following information received by email on October 10, 2019. Fumigation Date: 10/01/19 at 3:00 pm /Time of release of Vikane: 5:30 pm on 10/01/19 and 10:45 am on 10/02/19 Tear Down: 10/03/19/19 at 7:00 am On Tuesday October 1st, 2019 at (Time) x fumigated the structure located at (address), FL (zip) for DW Termites. The structure was fumigated by Mr. (name) # x. Before the fumigation took place, Mr. (name). confirmed with the owner that she had all pets in her possession and out of the structure, she signed an animal waiver, in addition to the OCC. At about at 7:00 pm Mr. (name). received a call from Homeowner stating that there was a possibility of one of the cats is under the tarp. (Name) contacted me immediately and I ordered (name) to go back to the property with Mr (name). to inspect the property. When arrived at the property, the Homeowner had already removed water snakes of one part of the house to try to see if in that way the cat could escape. Customer never entered the fumigated structure. After inspecting around the property exterior, (name) proceeded to enter the into the house with an SCBA, and he couldn't find anything inside the house or around it. This property has a crawl space so we are assuming if there was a cat inside it could be inside the crawl space. (name) did a visual inspection for a second time from the crawl space opening and he didn't see anything that appeared out of the ordinary. On Wednesday after doing another inspection of the property, (name) proceeded to close the house and shot the gas again. Today Thursday, October 3, 2019, after the down was completed, the (name) found a dead cat underneath a gas tank on the right side of the house. We contacted customer to notify her about the finding of the cat. Due to the location of the cat, underneath the gas tank, it was impossible to find it with the tarps on.

To be determined by Registrant

18. Severity classification (if there is more than 1 possible classification


19. Provide supplemental information here