Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2011-0261
2. Registrant Information.
Registrant Reference Number: 100126781
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.
28-SEP-10
5. Location of incident.
Country: CANADA
Prov / State: QUEBEC
6. Date incident was first observed.
28-SEP-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)
PMRA Registration No. 21744
PMRA Submission No.
EPA Registration No.
Product Name: Zodiac Flea and Tick Spray for Dogs and Cats
- Active Ingredient(s)
- (S)-METHOPRENE
- N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
- PIPERONYL BUTOXIDE
- PYRETHRINS
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: 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).
On September 28, 2010 the owner sprayed the product onto the dog.
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
Dog / Chien
3. Breed
Yorkshire Terrier Mix
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
3
7. Weight (provide a range if necessary )
8
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
<=15 min / <=15 min
10. Time between exposure and onset of symptoms
<=30 min / <=30 min
11. List all symptoms
System
12. How long did the symptoms last?
<=30 min / <=30 min
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?
Treatment / Traitement
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
On September 28, 2010 the dog may have inhaled some of the product and began sneezing. The owner rinsed the dog's coat/skin a few times shortly after the dog began sneezing. Shortly after the dog fully recovered, so the owner contacted the Animal Product Safety Service (APSS). The APSS veterinarian stated if he managed to breathe in a bit of the spray it could be a bit irritating to the nasal turbinates.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Minor
19. Provide supplemental information here
No significant signs are expected.