Déclaration d'incident

Sous-formulaire I: Renseignements généraux

1.Type de rapport.

Nouvelle déclaration d'incident

No de la demande: 2024-1611

2. Renseignements concernant le titulaire.

Numéro de référence du titulaire d'homologation: 3882461

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 l'humain

Défaillance de l'emballage

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

05-APR-24

5. Lieu de l'incident.

Pays: UNITED STATES

État: MARYLAND

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. 1021-1674-8845

Nom du produit: Hot Shot Bedbug & Flea Fogger

• Matière active
  • ESFENVALERATE
    • Inconnu
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • Inconnu
  • PIPERONYL BUTOXIDE
    • Inconnu
  • PYRETHRINS
    • Inconnu
  • PYRIPROXYFEN
    • Inconnu

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7. b) Type de formulation.

Autre (préciser)

Fogger

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?

Inconnu

Sous-formulaire II : Incident chez l'humain (Obligation d'utiliser un formulaire séparé pour chaque personne affectée)

1. Source de la déclaration.

Personne affectée

2. Renseignement démographique sur la personne affectée

Sexe: Femme

Âge: Unknown / Inconnu

3. Énumérez tous les symptômes, au moyen des choix suivants.

Système

• Sang
  • Symptôme - Autre
  • Specify - Blood poison

• General
  • Symptôme - Autre
  • Specify - Infection in leg

• Systèmes nerveux et musculaire
  • Symptôme - absence de réponse

• Système respiratoire
  • Symptôme - Autre
  • Specify - Lung infections

4. Quelle a été la durée des symptômes?

Unknown / Inconnu

5. La personne affectée a-t-elle reçu des soins médicaux? Donner les détails à la question 13.

Oui

6. a) Est-ce que la personne a été hospitalisée?

Inconnu

6. b) Pendant combien de temps?

Inconnu

7. Scénario d'exposition

Non professionnel

8. Comment l'exposition s'est-elle produite? (cocher tout ce qui s'applique)

Application

Quelle était l'activité? Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding the activity

9.Si l'exposition s'est produite lors du traitement ou au moment du retour dans la zone traitée, de l'équipement de protection individuelle était-il porté? (cocher tout ce qui s'applique)

Aucun

10. Voie(s) d'exposition.

Peau

Yeux

Respiratoire

11.Durée de l'exposition?

Unknown / Inconnu

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

Unknown / Inconnu

13.Donner tout détail additionnel au sujet de l'incident (p.ex. description des symptômes tels que la fréquence et la gravité, type de soins médicaux, résultats des tests médicaux, quantité de pesticide à laquelle la personne a été exposée, 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.

À être déterminé par le titulaire

14. Classification selon la gravité.

Majeure

15. 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.

Sous-formulaire VI : Défaillance de l'emballage

1. Type d'emballage défaillant?

Can / Cannette

2. La défaillance de l'emballage est apparue pendant?

L'utilisation du produit

3. La défaillance de l'emballage a donné lieu à :

une blessure potentielle

une exposition potentielle

4.Décrire pourquoi l'emballage a été défaillant et dans quelles circonstances, décrire notamment la blessure ou l'exposition potentielle.

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.

À l'usage du titulaire seulement

5. 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.