Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2022-5332

2. Registrant Information.

Registrant Reference Number: 3394477

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.

28-SEP-22

5. Location of incident.

Country: UNITED STATES

Prov / State: VERMONT

6. Date incident was first observed.

22-SEP-22

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)

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PMRA Registration No. 30164      PMRA Submission No.       EPA Registration No. 1021-1771

Product Name: PYGANIC Crop Protection EC 1.4 II

• Active Ingredient(s)
  • PYRETHRINS
    • Unknown

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 70870-1-68539

Product Name: Milstop Broad Spectrum Foliar Fungicide

• Active Ingredient(s)
  • POTASSIUM BICARBONATE

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7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Other / Autre

Préciser le type: Greenhouse

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?

Yes

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

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Female

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

3. List all symptoms, using the selections below.

System

• Cardiovascular System
  • Symptom - Chest pain

• General
  • Symptom - Fever
  • Symptom - Malaise
  • Symptom - Pain

• Nervous and Muscular Systems
  • Symptom - Numbness

4. How long did the symptoms last?

Unknown / Inconnu

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

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

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

Other

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.

Unknown

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.)

9/28/22-Caller works in a greenhouse and has been working there for 4 years. On 9/22/22 she suffered a Grand Mal seizure at work which included foaming at the mouth and urinary incontinence. She was transported by ambulance to the emergency room and did not go back to work until returning today. Upon her return today she learned that another employee she works with was hospitalized with symptoms of fever, chest and arm pain, numbness on the left side of her face, and unspecified illness. Her chest pain and sided facial numbness developed after other symptoms initially developed and she laid down to take a nap. She thought she was having a stroke upon waking, so presented to the emergency room over the past weekend, where the physician ruled out stroke, heart attack, and a virus. The hospitalization lasted for an unknown period of time, and no further information is available regarding her coworker's experience, treatment, diagnosis, or suspected cause. Some months ago when they were going to empty the green house they were advised the products were going to be added to the watering system fertilizers along with unspecified other products to keep bugs at bay. They added an unknown Prophylactic for white flies and fertilizers. She thinks the product is in the mixers and irrigation lines. Caller believes it is exposure to these products causing her and her coworker's symptoms. She took some soil and a water sample from the irrigation system and was going to have them tested. Caller is not included as a patient in this report as her symptoms and level of treatment do not elevate the incident to that of reportability for incidents occurring within the United States.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

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.

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

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Seizure

• Gastrointestinal System
  • Symptom - Foaming at mouth

• Renal System
  • Symptom - Urinary incontinence

4. How long did the symptoms last?

Unknown / Inconnu

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

Unknown

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Occupational

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

Other

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.

Unknown

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.