Incident Report

Subform I: General Information

1. Report Type.

Update the report

Incident Report Number: 2009-0771

2. Registrant Information.

Registrant Reference Number: 09-01-290391

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.

05-FEB-09

5. Location of incident.

Country: UNITED STATES

Prov / State: MICHIGAN

6. Date incident was first observed.

05-FEB-09

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. 2724-352

Product Name: Precor IGR Concentrate

• Active Ingredient(s)
  • (S)-METHOPRENE
    • Guarantee/concentration 1.2 %

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7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Other / Autre

Préciser le type: Human skin

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

Caller stated that the product was applied to another person's skin. The person is mentally ill and had also applied other pesticides to their skin.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

No

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Coma

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)

Other

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.

Skin

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

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.)

Caller found product in home and wanted to know the active ingredient. The person who applied the product to their own skin is mentally challenged and had also applied other products. The patient is in a coma in the hospital. No further information provided by caller.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

This was off label use of product: harmful if absorbed through the skin. Avoid contact with skin, eyes or clothing.