Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2023-1960

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.

09-FEB-23

5. Location of incident.

Country: UNITED STATES

Prov / State: FLORIDA

6. Date incident was first observed.

09-FEB-23

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

Respiratory

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• General
  • Symptom - Death

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?

Treatment / Traitement

17. Provide any additional details about the incident

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

[Name] of [Company] called me to discuss a situation regarding a cat at a fumigation. Here are his comments: we had a deceased cat at a job on 2/8-2/10 at [Address], [City], Fl [Postal code]. This house was a slab but had a small workshop in the back that had a small crawlspace that we had to cover. I had a discussion with the Homeowner upon arrival on 2/8 about that area and she assured me that the cats had been removed and we did look under the structure at that time. When We arrived on 2/9 to take the job down it was discovered by the front door. At the time we were being inspected by DACS and we informed the inspector ([Name]) who did not believe she needed any more information but was going to verify that with her supervisor. The cat has been buried on the property and the homeowner was informed. The structure has been cleared and is safe for reentry.

---

To be determined by Registrant

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

Death

19. Provide supplemental information here