Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2009-4982
2. Registrant Information.
Registrant Reference Number: 09-01-19793596
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.
Domestic Animal
4. Date registrant was first informed of the incident.
07-SEP-09
5. Location of incident.
Country: UNITED STATES
Prov / State: WISCONSIN
6. Date incident was first observed.
31-AUG-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.
PMRA Submission No.
EPA Registration No. 2724-490
Product Name: VetKem Siphotrol Plus II Premise Spray
- 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 %
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).
Product was applied to premise and it is unknown if cats were exposed to wet product.
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
Persian
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
9
7. Weight (provide a range if necessary )
4
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- General
- Symptom - Abnormal behaviour
- Specify - didn't want to come into the house
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?
Other / Autre
specify unknown
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Caller was advised by Prosar Specialist that once the product has dried, it is not expected to cause any symptoms of irritation. Specialist advised to take the pets to the veterinarian. Both cats passed away. A necropsy was not performed because the DVM did not preserve the cats properly.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
Unknown if cat was exposed to wet product. According to the specialist at Prosar, they would not expect exposure to small amounts of even the wet product to cause the described symptoms.
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
Domestic Short Hair
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
5
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- General
- Symptom - Pale mucous membrane colour
- Specify - pale gums
- Symptom - Vocalizing
- Symptom - Death
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?
Other / Autre
specify unknown
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Caller was advised by Prosar Specialist that once the product has dried, it is not expected to cause any symptoms of irritation. Specialist advised to take the pets to the veterinarian. Both cats passed away. A necropsy was not performed because the DVM did not preserve the cats properly.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here
Unknown if cat was exposed to wet product. According to the specialist at Prosar, they would not expect exposure to small amounts of even the wet product to cause the described symptoms.