Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-0923

2. Registrant Information.

Registrant Reference Number: 090113294

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.

08-OCT-09

5. Location of incident.

Country: UNITED STATES

Prov / State: UTAH

6. Date incident was first observed.

08-OCT-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. 2724-506

Product Name: Zodiac Triple Action 3 Flea and Tick Shampoo for Dogs and Cats

• Active Ingredient(s)
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration 1.5 %
  • PYRETHRINS
    • Guarantee/concentration .15 %

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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: Animal / Usage sur un animal domestique

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

A flea and tick collar was applied to the kitten on October 7, 2009. On October 8, 2009 the owner bathed the kitten with the product to treat for fleas.

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

Domestic Shorthair

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

0.25

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Skin

9. What was the length of exposure?

>15 min <=2 hrs / >15 min <=2 h

10. Time between exposure and onset of symptoms

<=30 min / <=30 min

11. List all symptoms

System

• General
  • Symptom - Lethargy

• Nervous and Muscular Systems
  • Symptom - Abasia

• General
  • 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?

Treatment / Traitement

17. Provide any additional details about the incident

(eg. description of the frequency and severity of the symptoms

The APSS veterinarian stated the main concern is for gastrointestinal (GI) upset, a taste reaction, and dermal hypersensitivity with this exposure. She also stated that generally flea collars used appropriately are fairly safe, but if the cat licks at the collar dust or collar, it is possible to see a taste reaction and GI upset. She further stated that the signs could be due to flea bite anemia. The APSS technician relayed the APSS veterinarian's recommendations to the owner; rub a small amount of Karo syrup on the gums in case the kitten is hypoglycemic, take the kitten to a veterinarian for evaluation, have the veterinarian call back for information, and call back with questions.

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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 that the substance was considered to have a doubtful likelihood of causing the clinical situation. The owner reported that the cat died on October 8, 2009 after the APSS consultation.