Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2007-8896
2. Registrant Information.
Registrant Reference Number: 070095297
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.
06-SEP-07
5. Location of incident.
Country: UNITED STATES
Prov / State: NEW YORK
6. Date incident was first observed.
04-SEP-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. 4758-175-2724
Product Name: Zodiac Fleatrol Carpet and Upholstery Powder 4758-175-2724
- Active Ingredient(s)
- PIPERONYL BUTOXIDE
- Guarantee/concentration .5 %
- PYRETHRINS
- Guarantee/concentration .075 %
- PYRIPROXYFEN
- Guarantee/concentration .02 %
7. b) Type of formulation.
Dust
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).
On September 3, 2007, the owner applied the product to her carpet and then vacuumed the area one hour later. The animal was allowed in the area after the product had been vacuumed.
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
Cat / Chat
3. Breed
Domestic Shorthair Cat
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
5
7. Weight (provide a range if necessary )
14
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
>24 hrs <=3 days / >24 h <=3 jours
10. Time between exposure and onset of symptoms
>24 hrs <=3 days / >24 h <=3 jours
11. List all symptoms
System
- Nervous and Muscular Systems
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?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Owner advised APSS cat jumped from 7 ft dresser and did not land on it's feet. Cat tried to get up, started tremoring, convulsed one time and died. APSS veterinarian advised owner that the product did not kill the cat. APSS discussed with owner possiblity of an embolism or a brain tumor.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
It is unclear if an exposure occured. A necropsy was recommended but the animal was already buried. APSS stated trauma was considered to have high likelihood of causing the clinical situation. APSS suspects underlying heart condition and possibility of embolism or brain tumor.