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Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2010-3814
2. Registrant Information.
Registrant Reference Number: 100062793
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.
19-MAY-105. Location of incident.
Country: UNITED STATES
Prov / State: CALIFORNIA
6. Date incident was first observed.
19-MAY-10Product 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: Vet Kem 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 %
- (S)-METHOPRENE
7. b) Type of formulation.
Other (specify)
AerosolApplication 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 18, 2010 the owner applied the product in his home after removing the chameleon from the house.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
Other / Autre
specify Lizard
3. Breed
Chameleon Unspecified
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
1.5
7. Weight (provide a range if necessary )
Unknown
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 - 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?
Contact treat.area/Contact surf. traitée
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
On May 18, 2010, three and a half to four and a half hours after the product was applied, the owner brought the chameleon back into the house and the next morning on May 19, 2010 the owner found the Chameleon dead. The APSS veterinarian stated the time of exposure and sudden death are not related to this product. The APSS veterinarian also stated inhalation may cause a possible allergic reaction, but not sudden death. The APSS veterinarian recommended contacting the manufacturer and discussing a necropsy with his regular veterinarian. The owner stated he would contact his veterinarian and have them call the APSS for further instructions.
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 not related to causing the clinical situation. On May 20, 2010 an APSS technician contacted the attending veterinary clinic to follow up on the necropsy. The veterinary staff stated the owner hadn't given them his decision on the necropsy yet. The veterinary staff stated she would contact the owner and call the APSS if he decides to proceed with the necropsy.
