Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2010-5555

2. Registrant Information.

Registrant Reference Number: 100101850

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.

05-AUG-10

5. Location of incident.

Country: UNITED STATES

Prov / State: NEW JERSEY

6. Date incident was first observed.

05-AUG-10

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. 2724-274

Product Name: Starbar Golden Malrin Fly Bait 1% Methomyl

• Active Ingredient(s)
  • (Z)-9-TRICOSENE
    • Guarantee/concentration .049 %
  • METHOMYL
    • Guarantee/concentration 1 %

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7. b) Type of formulation.

Bait

Application Information

8. Product was applied?

Unknown

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

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

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

Medical Professional

2. Type of animal affected

Dog / Chien

3. Breed

Siberian Husky

4. Number of animals affected

1

5. Sex

Female

6. Age (provide a range if necessary )

0.83

7. Weight (provide a range if necessary )

55

lbs

8. Route(s) of exposure

Oral

9. What was the length of exposure?

Unknown / Inconnu

10. Time between exposure and onset of symptoms

Unknown / Inconnu

11. List all symptoms

System

• Nervous and Muscular Systems
  • Symptom - Seizure

• General
  • Symptom - Death

12. How long did the symptoms last?

>2 hrs <=8 hrs / > 2 h < = 8 h

13. Was medical treatment provided? Provide details in question 17.

Yes

14. a) Was the animal hospitalized?

Yes

14. b) How long was the animal hospitalized?

Unknown

15. Outcome of the incident

Died

16. How was the animal exposed?

Accidental ingestion/Ingestion accident.

17. Provide any additional details about the incident

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

On August 5, 2010 the attending veterinary staff contacted the Animal Product Safety Service (APSS) after the dog had presented at the clinic with symptoms. The dog had an ingested an unknown amount of the product at an unknown time. The APSS veterinarian stated that the methomyl in the product is a hot carbamate insecticide with a narrow margin of safety and rapid onset of signs. She recommended managing seizures, monitoring the heart rate and respirations, giving atropine, and having the attending veterinarian call back for further information.

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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

On August 10, 2010 an APSS technician contacted the attending veterinary clinic to update the case. The veterinary staff person informed her that the dog had died that same day. This product was not used according to label directions: Do not use in areas where animals have access to.