Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-0857

2. Registrant Information.

Registrant Reference Number: 100147750

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.

15-NOV-10

5. Location of incident.

Country: UNITED STATES

Prov / State: CONNECTICUT

6. Date incident was first observed.

01-NOV-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. 73049-300-2724

Product Name: Zodiac Flea and Tick Sponge On

• Active Ingredient(s)
  • PIPERONYL BUTOXIDE
    • Guarantee/concentration 3 %
  • PYRETHRINS
    • Guarantee/concentration .3 %

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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).

On October 27, 2010 the pet store owner applied the dip to to the under labelled aged kittens.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

No

Subform III: Domestic Animal Incident Report

1. Source of Report

Medical Professional

2. Type of animal affected

Cat / Chat

3. Breed

Domestic Shorthair

4. Number of animals affected

3

5. Sex

Unknown

6. Age (provide a range if necessary )

0.211

7. Weight (provide a range if necessary )

Unknown

8. Route(s) of exposure

Skin

9. What was the length of exposure?

>24 hrs <=3 days / >24 h <=3 jours

10. Time between exposure and onset of symptoms

>24 hrs <=3 days / >24 h <=3 jours

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?

Treatment / Traitement

17. Provide any additional details about the incident

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

On November 1, 2010 two of the kittens died. On November 10, 210 another kitten died. On November 15, 2010 the attending veterinarian called the Animal Product Safety Service (APSS). The APSS veterinarian stated five days after the exposure, signs will not be expected. The APSS veterinarian also stated this is not likely related to this exposure and without good history and necropsy, cause of death and illness cannot be determined. A necropsy was not possible as the bodies were not available.

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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

This product was not used according to label directions: do not use on dogs or cats under 12 weeks old..