Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2020-1083
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.
26-MAR-20
5. Location of incident.
Country: UNITED STATES
Prov / State: FLORIDA
6. Date incident was first observed.
25-MAR-20
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. 28240
PMRA Submission No.
EPA Registration No. 1015-78
Product Name: VIKANE
- Active Ingredient(s)
- SULFURYL FLUORIDE
- Guarantee/concentration 99.8 %
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).
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Unknown
Subform III: Domestic Animal Incident Report
1. Source of Report
Other
2. Type of animal affected
Cat / Chat
3. Breed
unknown
4. Number of animals affected
1
5. Sex
Unknown
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
No
14. a) Was the animal hospitalized?
No
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
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 March 26, 2020. Fumigation in (city), FL. Was put up march 18th, taken down on the 19th, and cleared on March 20th. On March 25th was notified about a cat According to Fumigation manager "Basically my understanding is that no one in the crew was aware or told about any animals under the crawl, the customer contacted the local branch only after the smell became intolerable, and then they realized it was a cat but it was not theirs".
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here