Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2009-0830

2. Registrant Information.

Registrant Reference Number: 09-01-17463857

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.

03-FEB-09

5. Location of incident.

Country: UNITED STATES

Prov / State: COLORADO

6. Date incident was first observed.

Unknown

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. 4758-175-2596

Product Name: Advanced Care 3 in 1 Carpet Powder

• Active Ingredient(s)
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration .5 %
  • PYRETHRINS
    • Guarantee/concentration .08 %
  • PYRIPROXYFEN
    • Guarantee/concentration .02 %

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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).

Approximately one-half of the product in the container was used in the home over the month prior to the report.

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: Female

Age: >64 yrs / > 64 ans

3. List all symptoms, using the selections below.

System

• Nervous and Muscular Systems
  • Symptom - Confusion
  • Specify - "Dementia"
  • Symptom - Difficulty walking
  • Specify - "Unable to walk"

• General
  • Symptom - Abnormal behaviour
  • Specify - "Sitting on the floor for hours watching a blank TV"

• Nervous and Muscular Systems
  • Symptom - Other
  • Specify - "Neurological disorder "

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)

Unknown

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

>1 wk <=1 mo / > 1 sem < = 1 mois

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 reported the exposure of his elderly mother to an insecticide carpet powder containing the active ingredients on Feb 03/09. The caller's mother had been using the product in her home for about the past month. At the time of the report, half of the container had been used and the caller wondered whether his mother had used too much. She also did not vacuum the product following application. According to the caller, his mother had been hospitalized about 1 week prior to the report for evaluation/treatment of dementia and an inability to walk. She was also recently found sitting on the floor for hours watching a blank TV. The reporter also stated that she had been recently diagnosed with a neurologic disorder (reporter did not know details of diagnosis) based on an MRI. The caller did not say whether his mother was still hospitalized and what, if any, treatments she had received.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

Caller was advised that symptoms as described are not expected with proper use of the product. Per the labelled directions, visible powder on surfaces should be vaccumed up.