Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2007-7274

2. Registrant Information.

Registrant Reference Number: 071-15224420

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

Address: 100 Stone Road West, Suite 111

City: Guelph

Prov / State: ON

Country: Canada

Postal Code: N1G 5L3

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

Human

4. Date registrant was first informed of the incident.

17-AUG-07

5. Location of incident.

Country: UNITED STATES

Prov / State: OHIO

6. Date incident was first observed.

16-AUG-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)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No.

Product Name: Zodiac Advanced Indoor Spray EPA #2724-490

• Active Ingredient(s)
  • (S)-METHOPRENE
    • Guarantee/concentration .085 %
  • D-PHENOTHRIN
  • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
    • Guarantee/concentration 2 %
  • PERMETHRIN
    • Guarantee/concentration .35 %
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration 1.4 %

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7. b) Type of formulation.

Other (specify)

Aerosol

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).

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.

Medical Professional

2. Demographic information of data subject

Sex: Male

Age: >19 <=64 yrs / >19 <=64 ans

3. List all symptoms, using the selections below.

System

• Respiratory System
  • Symptom - Coughing
  • Symptom - Respiratory failure
  • Symptom - Shortness of breath
  • Symptom - Pneumonia
  • Symptom - Other
  • Specify - lung injury

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?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

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

Application

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.

Respiratory

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

>24 hrs <=3 days / >24 h <=3 jours

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.)

Patient applied aerosol product August 13 or 14, 2007. History not clear. Since then, patient had progressively worsening coughing and SOB. Presented to hospital on August 16, 2007, required mechanical ventilation shortly upon admission. Attending physician states it is possible patient had been SOB prior to using product. Physician advised chest X-ray showed either pneumonia or lung injury.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

PROSAR advised attending physician that would not expect product to produce tissue damage upon inhalation.