Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-1329
2. Registrant Information.
Registrant Reference Number: 10-01-21282490
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.
11-JAN-10
5. Location of incident.
Country: CANADA
Prov / State: NOVA SCOTIA
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)
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).
Premise product was applied to residence several times approximately 6 weeks ago.
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Unknown
Subform II: Human Incident Report (A separate form for each person affected)
1. Source of Report.
Data Subject
2. Demographic information of data subject
Sex: Female
Age: >19 <=64 yrs / >19 <=64 ans
3. List all symptoms, using the selections below.
System
- Skin
- Symptom - Pruritus
- Symptom - Rash
4. How long did the symptoms last?
>1 mo and <= 2mos / >1 mois et < = 2mois
5. Was medical treatment provided? Provide details in question 13.
Unknown
6. a) Was the person hospitalized?
No
6. b) For how long?
7. Exposure scenario
Non-occupational
8. How did exposure occur? (Select all that apply)
Contact with treated area
9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)
None
10. Route(s) of exposure.
Skin
Respiratory
11. What was the length of exposure?
Unknown / Inconnu
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 used antihistamines and topical corticosteroids and still has symptoms.
To be determined by Registrant
14. Severity classification.
Major
15. Provide supplemental information here.
Caller was advised by Prosar Specialist that if symptoms do not resolve within 72 hours, consult a health care professional. Caller was also advised to discontinue product use, that there are many causes of skin rashes, and was advised of cleaning instructions.