Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2024-1611

2. Registrant Information.

Registrant Reference Number: 3882461

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

Packaging Failure

4. Date registrant was first informed of the incident.

05-APR-24

5. Location of incident.

Country: UNITED STATES

Prov / State: MARYLAND

6. Date incident was first observed.

Unknown

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.       PMRA Submission No.       EPA Registration No. 1021-1674-8845

Product Name: Hot Shot Bedbug & Flea Fogger

• Active Ingredient(s)
  • ESFENVALERATE
    • Unknown
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • Unknown
  • PIPERONYL BUTOXIDE
    • Unknown
  • PYRETHRINS
    • Unknown
  • PYRIPROXYFEN
    • Unknown

---

7. b) Type of formulation.

Other (specify)

Fogger

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).

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?

Unknown

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

• Blood
  • Symptom - Other
  • Specify - Blood poison

• General
  • Symptom - Other
  • Specify - Infection in leg

• Nervous and Muscular Systems
  • Symptom - Unresponsive

• Respiratory System
  • Symptom - Other
  • Specify - Lung infections

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?

Unknown

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

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

Application

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

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

None

10. Route(s) of exposure.

Skin

Eye

Respiratory

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.)

4/5/2024 The following information was received by MGK's partner, (company name), on 5APR24 and forwarded via email to MGK on 12APR24 for awareness and reporting purposes: The consumer states this happened last year April/ March. Someone says she wants a supervisor. The consumer states she wants a supervisor so she cant talk about her hospital bill to be paid for. The consumer states the button didn't go off and the 2nd time and the product went into her lungs and her face and went everywhere. The consumer called and states she used a product last year that exploded and she has lung infections and blood poison and a infection in her leg. The consumer has to use a oxygen machine on occasion The consumer states she has infection in her leg. The consumer stated she has states she has not paid any of the hospital bill as yet. Consumer states went into her eyes her face and lungs. The consumer states she didn't call sooner she was waiting for her insurance. The consumer is worried if this happens to other people. Consumer said her son found her unresponsive. The consumer states she has tried to call the ambulance people to find out if they brought her back to life. The consumer states she kind of remembers her son asking if she should call 911. Consumer does not know how long she was in the hospital. 2024-04-05 The consumer stated she still has the can somewhere in the house. Advised they may want to issue a call tag. Advised I can open a claim. The consumer still wants to speak to a supervisor. 2024-04-05 Advised I can take her information and still open the claim and we would forward to have a supervisor call her back. Advised (company name) handles the claim and she needs to wait until she hears back 2-3 weeks. Advised we will forward to have [(company name) employee name redacted for privacy] call her back with her questions. Consumer states her insurance refuses to pay for the bills. Advised the consumer we will issue a call tag to have the cans sent back. 2024-04-05 call was disconnected tried to call the consumer back and cannot leave a message. [(company name) employee named redacted for privacy] is aware and will notify [(company name) employee name redacted for privacy] today. Advised consumer to wait to hear back from (company name) in 2-3 weeks regarding her claim and about the call tag . 2024-04-05 Called [name redacted for privacy] - left a message. 2024-04-05 I was able to get ahold of the her and advised the information. 2024-04-05 I called the consumer at 4:38 pm. The line was busy and the mailbox was full. Unable to leave a message. No further information is available regarding the consumeras symptoms or treatment, nor is further information known about the issue with the product can.

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 VI: Packaging Failure

1. What is the type of packaging that failed?

Can / Cannette

2. Did packaging failure occur during?

Use of Product

3. Did packaging failure result in?

potential injury

potential exposure

4. Describe how the packaging failed and the surrounding circumstances, including a description of the potential injury or exposure.

4/5/2024 The following information was received by MGK's partner, Spectrum Brands, on 5APR24 and forwarded via email to MGK on 12APR24 for awareness and reporting purposes: The consumer states this happened last year April/ March. Someone says she wants a supervisor. The consumer states she wants a supervisor so she cant talk about her hospital bill to be paid for. The consumer states the button didn't go off and the 2nd time and the product went into her lungs and her face and went everywhere. The consumer called and states she used a product last year that exploded and she has lung infections and blood poison and a infection in her leg. The consumer has to use a oxygen machine on occasion The consumer states she has infection in her leg. The consumer stated she has states she has not paid any of the hospital bill as yet. Consumer states went into her eyes her face and lungs. The consumer states she didn't call sooner she was waiting for her insurance. The consumer is worried if this happens to other people. Consumer said her son found her unresponsive. The consumer states she has tried to call the ambulance people to find out if they brought her back to life. The consumer states she kind of remembers her son asking if she should call 911. Consumer does not know how long she was in the hospital. 2024-04-05 The consumer stated she still has the can somewhere in the house. Advised they may want to issue a call tag. Advised I can open a claim. The consumer still wants to speak to a supervisor. 2024-04-05 Advised I can take her information and still open the claim and we would forward to have a supervisor call her back. Advised Sedgewick handles the claim and she needs to wait until she hears back 2-3 weeks. Advised we will forward to have [Spectrum employee name redacted for privacy] call her back with her questions. Consumer states her insurance refuses to pay for the bills. Advised the consumer we will issue a call tag to have the cans sent back. 2024-04-05 call was disconnected tried to call the consumer back and cannot leave a message. [Spectrum employee named redacted for privacy] is aware and will notify [Spectrum employee name redacted for privacy] today. Advised consumer to wait to hear back from Sedgewick in 2-3 weeks regarding her claim and about the call tag . 2024-04-05 Called [name redacted for privacy] - left a message. 2024-04-05 I was able to get ahold of the her and advised the information. 2024-04-05 I called the consumer at 4:38 pm. The line was busy and the mailbox was full. Unable to leave a message. No further information is available regarding the consumeras symptoms or treatment, nor is further information known about the issue with the product can.

For Registrant use only

5. 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.