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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2020-3026

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.


4. Date registrant was first informed of the incident.


5. Location of incident.


Prov / State: CALIFORNIA

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 / Rs. - 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 II: Human Incident Report (A separate form for each person affected)

1. Source of Report.


2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

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.)

Brief Incident Description Notes. Date: July 21, 2020 Douglas Salesperson notified via phone from PCO of alleged death at a treatment site. Statements from the PCO: Homeowner called the prime contractor to report a possible break-in at her home during the fumigation process. She saw two slashes in the tent. She went by the property because she had been calling her husband and he wasn't responding. She used the find an iPhone function and his location showed up close to their home. The PCO who applied the treatment was notified and went to the house and arrived at around 2:45 pm. The homeowner was still at the property. Upon entering the house, the PCO entered a bedroom where he found a body laying face down on the floor. He left the structure and told the homeowner to call 911. He called his office and told them to call (city) AG dept. First responders arrived, entered the home, pronounced the individual dead at the scene. The same Douglas Salesperson sent an internal communication notifying of this incident. This included a link to a (station) news article titled: (name of article). Date: July 23, 2020 The Douglas Salesperson went to the job site to witness the removal of the tarps and the certification of the property with the PCO after the facility was cleared by authorities. He noted: the doors all had secondary locks during the fumigation. a chloropicrin pan was present in the home. the PCO showed him where the two slashes in the tent were and they were close to the kitchen door. the kitchen door had been opened by force and the door jam had been broken.

To be determined by Registrant

14. Severity classification.


15. Provide supplemental information here.