Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2009-2163
2. Registrant Information.
Registrant Reference Number: 090059896
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.
01-JUN-09
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
29-MAY-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)
PMRA Registration No. 25695
PMRA Submission No.
EPA Registration No.
Product Name: Zodiac Premise 2000 Flea Spray
- Active Ingredient(s)
- (S)-METHOPRENE
- PERMETHRIN
7. b) Type of formulation.
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 May 29, 2009, the owner sprayed the product in a room while the dog was present.
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
Maltese Dog Poodle Dog Mix
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
0.15
7. Weight (provide a range if necessary )
1.5
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- General
- Symptom - Lethargy
- Symptom - Death
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
Unknown
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
The APSS technician stated that signs are expected to be mild and self limiting. The APSS technician recommended that the owner take the pet to the veterinarian, have the veterinarian call back for information, and call back with questions.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
The APSS veterinarian stated the product was not related to the clinical signs. This product was not used according to label directions: keep children and pets away from treated surfaces until dry. Upon follow up, the owner stated he had taken the pet to the veterinarian where the pet was diagnosed with parvovirus.