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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-0188
2. Registrant Information.
Registrant Reference Number: 090098645
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-SEP-095. Location of incident.
Country: CANADA
Prov / State: QUEBEC
6. Date incident was first observed.
25-AUG-09Product 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. 25739 PMRA Submission No. EPA Registration No.
Product Name: Vet Kem Siphotrol 1000 Double Action Premise Treatment
- 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 August 22, 2009 the pet owner treated her home with the product.To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
YesSubform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
Domestic Shorthair
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
5.5
7. Weight (provide a range if necessary )
10
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>1 wk <=1 mo / > 1 sem < = 1 mois
11. List all symptoms
System
- Respiratory System
- Symptom - Coughing
- Gastrointestinal System
- Symptom - Retching
12. How long did the symptoms last?
Unknown / Inconnu
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
Not recovered / Non rétabli
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 veterinarian stated that coughing would not be expected with an exposure to the product residue. She recommended that the pet owner take the cat to the veterinarian and have the veterinarian call with questions if needed.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here
The APSS veterinarian stated that the substance was considered to have a doubtful likelihood of causing the clinical situation. On September 8, 2009 an APSS technician spoke to the pet owner. The cat was not exposed to wet product. The pet owner monitored the cat at home and did not take the cat to the veterinarian.
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Cat / Chat
3. Breed
Himalayan
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
10.5
7. Weight (provide a range if necessary )
10.0
lbs
8. Route(s) of exposure
Unknown
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>3 days <=1 wk / >3 jours <=1 sem
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Vomiting
- Respiratory System
- Symptom - Coughing
12. How long did the symptoms last?
>1 wk <=1 mo / > 1 sem < = 1 mois
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
Fully Recovered / Complètement rétabli
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 veterinarian stated that the signs would not be expected with an exposure to the product residue. She recommended that the pet owner take the cat to the veterinarian and have the veterinarian call with questions if needed.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here
The APSS veterinarian stated that the substance was considered to have a doubtful likelihood of causing the clinical situation. On September 8, 2009 an APSS technician spoke to the pet owner. The pet owner stated that she monitored the cat at home, and the cat made a full recovery on September 3, 2009. The pet owner did not take the cat to the veterinarian.
