Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-4765

2. Registrant Information.

Registrant Reference Number: 140108487

Registrant Name (Full Legal Name no abbreviations): Wellmark International

Address: 100 Stone Road West, Suite 111

City: Guelph

Prov / State: Ontario

Country: Canada

Postal Code: N1G5L3

3. Select the appropriate subform(s) for the incident.

Domestic Animal

4. Date registrant was first informed of the incident.

27-AUG-14

5. Location of incident.

Country: CANADA

Prov / State: ONTARIO

6. Date incident was first observed.

26-AUG-14

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. 15176      PMRA Submission No.       EPA Registration No.

Product Name: Agricultural Starbar Premium Fly Bait with Muscamone

• Active Ingredient(s)
  • (Z)-9-TRICOSENE
  • METHOMYL

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7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Agricultural-Indoor / Agricole-intérieur

Préciser le type: Windowsill

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

On August 26, 2014 the owner put the product on a windowsill about 6 feet above where the chickens are and have no way of getting to it. The owner is concerned with a relay exposure (if the flies eat the bait, die and the chickens eat the flies).

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

Animal's Owner

2. Type of animal affected

Bird - Poultry / Oiseau - Volaille

3. Breed

Chicken Unspecified

4. Number of animals affected

2

5. Sex

Female

6. Age (provide a range if necessary )

Unknown

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

<=30 min / <=30 min

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?

Other / Autre

specify Relay

17. Provide any additional details about the incident

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

On August 26, 2014 the owner found 2 chickens dead. On August 27, 2014 the owner contacted the Animal Product Safety Service (APSS). The APSS veterinarian stated relay toxicity would be unlikely and we don't expect death from a secondary ingestion. The APSS assistant recommended a necropsy (or blood work to see if the poison was involved) or discontinuing product usage (to see if any more deaths occur). The APSS assistant also recommended calling back with questions (if signs persist, progress, or new signs present in the other chickens).

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To be determined by Registrant

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

Death

19. Provide supplemental information here

The APSS veterinarian stated that the substance was considered to have an unknown likelihood of causing the clinical situation.