Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2007-6009
2. Registrant Information.
Registrant Reference Number: 070061661
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.
17-JUN-07
5. Location of incident.
Country: UNITED STATES
Prov / State: MISSOURI
6. Date incident was first observed.
17-JUN-07
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. 2724274
Product Name: Starbar Golden Malrin Fly Bait
- Active Ingredient(s)
- (Z)-9-TRICOSENE
- Guarantee/concentration .049 %
- METHOMYL
- Guarantee/concentration 1.1 %
7. b) Type of formulation.
Bait
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Res. - Out Home / Rés - à l'ext.maison
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
On June 17, 2007 at 5:55 pm CDT, the owner covered the bottom of a paper plate with 2 T. of said product. The owner did not specify if the product was applied to the plate inside or outside of the home. The owners 8 year old, 13 pound, spayed female, Rat Terrier ingested the said product from the plate.
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
No
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Rat Terrier
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
8
7. Weight (provide a range if necessary )
13
lbs
8. Route(s) of exposure
Oral
9. What was the length of exposure?
>15 min <=2 hrs / >15 min <=2 h
10. Time between exposure and onset of symptoms
<=30 min / <=30 min
11. List all symptoms
System
- Nervous and Muscular Systems
- Symptom - Seizure
- Symptom - Trembling
- Gastrointestinal System
- Symptom - Salivating excessively
12. How long did the symptoms last?
<=30 min / <=30 min
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 Accidental ingestion
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
On June 17th, 2007 at 6:01 pm, CDT, the owner contacted APSS to report the exposure and the signs her animal was displaying. Owner later contacted APSS to advise the animal died.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
Product not used according to label directions. Label states product not to be used inside or around homes or any other place where children or pets are likely to be present.