Déclaration d'incident

Sous-formulaire I: Renseignements généraux

1.Type de rapport.

Nouvelle déclaration d'incident

No de la demande: 2013-1747

2. Renseignements concernant le titulaire.

Numéro de référence du titulaire d'homologation: 1067083

Nom du titulaire (nom légal complet, aucune abbréviation): McLaughlin Gormley King Company

Adresse: 8810 Tenth Ave North

Ville: Minneapolis

État: MN

Pays: USA

Code postal /Zip: 55427-4319

3.Choisir le (les) sous-formulaire(s) correspondant à l'incident.

Incident chez un animal domestique

4. Date à laquelle le titulaire d'homologation a été informé pour la première fois de l'incident.

01-NOV-12

5. Lieu de l'incident.

Pays: UNITED STATES

État: MICHIGAN

6. Date de la première observation de l'incident.

Inconnu

Description du produit

7. a) Donner le nom de la matière active et, si disponibles, le numéro d'homologation et le nom du produit (incluant tous les mélanges). Si le produit n'est pas homologué, donner le numéro de la demande d'homologation.

Matière(s) active(s)

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ARLA No d'homologation       ARLA No de la demande d'homologation       EPA No d'homologation. 1021-1855-506

Nom du produit: TAT Roach & Ant Killer3

• Matière active
  • CYPERMETHRIN
    • Garantie/concentration .03 %
  • PRALLETHRIN
    • Garantie/concentration .011 %
  • PYRETHRINS
    • Garantie/concentration .011 %

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7. b) Type de formulation.

Liquide

Renseignments sur l'application

8. Est-ce que le produit a été appliqué?

Oui

9. Dose d'application.

Inconnu

10. Site d'application (choisir tout ce qui s'applique).

Site: Res. - In Home / Rés. - à l'int. maison

11. Donner tout renseignement additionnel concernant l'application (comment le produit a été appliqué, la quantité utilisée, la superficie de la zone traitée, etc.)

Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding application.

À être déterminé par le titulaire

12. Selon vous, le produit a-t-il été utilisé en conformité avec le mode d'emploi de L'étiquette?

Oui

Sous-formulaire III : Animal domestique

1. Source de la déclaration

Propriétaire de l'animal

2.Type d'animal touché

Cat / Chat

3. Race

DSH

4. Nombre d'animaux touchés

1

5. Sexe:

Femme

6. Âge (fournir un ordre de grandeur si nécessaire)

2

7. Poids (fournir un ordre de grandeur si nécessaire)

2.50

lbs

8. Voie(s) d'exposition:

Inconnu

9. Durée de l'exposition?

Unknown / Inconnu

10. Temps écoulé entre l'exposition et l'apparition des symptômes

Unknown / Inconnu

11. Énumérer tous les symptômes

Système

• Système gastro-intestinal
  • Symptôme - Anorexie

• General
  • Symptôme - Mort

12. Quelle a été la durée des symptômes?

Persisted until death

13. Des soins médicaux ont-ils été prodigués? Donner les détails à la question 17.

Non

14. a) Est-ce que l'animal a-t-il été hospitalisé?

Non

14. b) Combien de temps l'animal était-il hospitalisé?

15. Issue de l'incident

Mort

16. De quelle manière l'animal a-t-il été exposé?

Other / Autre

préciser Defined point of exposure not evident or witnessed. Exposure based on speculation.

17. Donnez tout détail additionnel au sujet de l'incident

(p.ex. description des symptômes tels que la fréquence et la gravité

11/1/2012 Caller is a poor historian who had trouble recounting events. Caller began using product over the summer to combat flies around her home. Caller states that one of her cats name Angel died but she was not able to elucidate when Angel died or the nature of Angel's veterinary care prior to death. All she was able to say was that Angel was not eating normally prior to dying. Angel was never witnessed eating flies. Caller's other cat named Patches began not eating normally and hiding on 10/25/12. The cat also had itching which was present beforehand. Caller took the cat to the veterinarian the following day, and determined that the cat has diabetes. The cat tested negative for feline leukemia. The veterinarian believes itching was due to fleas, and cat was given Benadryl. The cat was also given antibiotics. She continues not to eat normally. Caller is wondering if her cats could be affected by flies she speculates they may have eaten prior to the onset of their illnesses. 11/5/2012 Callback to he original caller for follow up information. Caller states she doesn't have money to start cat on insulin. She is currently feeding the cat soft food and water, but has not gotten the cat to eat solid food.

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À être déterminé par le titulaire

Classification selon la gravité (s'il y a plus d'une catégorie possible, veuillez choisir la plus grave)

Mort

19. Donner des renseignements additionnels ici

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. Any relationship between the use of this product and the insidious development of the illnesses reported in this case are inconceivable and lack biological plausibility. Secondly, the product use history is extremely vague and lacks any description of a known or defined point of direct exposure to this product. Even had casual or incidental contact with this product occurred, such illness as reported would be unexpected and are not consistent with the toxicological profile of this product..

Sous-formulaire III : Animal domestique

1. Source de la déclaration

Propriétaire de l'animal

2.Type d'animal touché

Cat / Chat

3. Race

DSH

4. Nombre d'animaux touchés

1

5. Sexe:

Femme

6. Âge (fournir un ordre de grandeur si nécessaire)

6

7. Poids (fournir un ordre de grandeur si nécessaire)

4.00

lbs

8. Voie(s) d'exposition:

Inconnu

9. Durée de l'exposition?

Unknown / Inconnu

10. Temps écoulé entre l'exposition et l'apparition des symptômes

Unknown / Inconnu

11. Énumérer tous les symptômes

Système

• Système gastro-intestinal
  • Symptôme - Anorexie

• General
  • Symptôme - Autre
  • Specify - Diabetes

• Peau
  • Symptôme - Prurit

12. Quelle a été la durée des symptômes?

Unknown / Inconnu

13. Des soins médicaux ont-ils été prodigués? Donner les détails à la question 17.

Oui

14. a) Est-ce que l'animal a-t-il été hospitalisé?

Non

14. b) Combien de temps l'animal était-il hospitalisé?

15. Issue de l'incident

Unknown/Inconnu

16. De quelle manière l'animal a-t-il été exposé?

Other / Autre

préciser Defined point of exposure not evident or witnessed. Exposure based on speculation.

17. Donnez tout détail additionnel au sujet de l'incident

(p.ex. description des symptômes tels que la fréquence et la gravité

11/1/2012 Caller is a poor historian who had trouble recounting events. Caller began using product over the summer to combat flies around her home. Caller states that one of her cats name Angel died but she was not able to elucidate when Angel died or the nature of Angel's veterinary care prior to death. All she was able to say was that Angel was not eating normally prior to dying. Angel was never witnessed eating flies. Caller's other cat named Patches began not eating normally and hiding on 10/25/12. The cat also had itching which was present beforehand. Caller took the cat to the veterinarian the following day, and determined that the cat has diabetes. The cat tested negative for feline leukemia. The veterinarian believes itching was due to fleas, and cat was given Benadryl. The cat was also given antibiotics. She continues not to eat normally. Caller is wondering if her cats could be affected by flies she speculates they may have eaten prior to the onset of their illnesses. 11/5/2012 Callback to he original caller for follow up information. Caller states she doesn't have money to start cat on insulin. She is currently feeding the cat soft food and water, but has not gotten the cat to eat solid food.

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À être déterminé par le titulaire

Classification selon la gravité (s'il y a plus d'une catégorie possible, veuillez choisir la plus grave)

Modérée

19. Donner des renseignements additionnels ici

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. Any relationship between the use of this product and the insidious development of the illnesses reported in this case are inconceivable and lack biological plausibility. Secondly, the product use history is extremely vague and lacks any description of a known or defined point of direct exposure to this product. Even had casual or incidental contact with this product occurred, such illness as reported would be unexpected and are not consistent with the toxicological profile of this product..